Independent Oversight and Assurance Group on Tayside's Mental Health Services: letter discussing patient safety on 22 July 2022

To

Grant Archibald
Chief Executive, NHS Tayside

Greg Colgan
Chief Executive, Dundee City Council

Phil Davison
Divisional Commander, Tayside Police Scotland

Thomas Glen
Chief Executive, Perth and Kinross Council

Margo Williamson
Chief Executive, Angus Council

22 July 2022

Dear Colleagues

Patient safety work plan - final question set

I wanted to share with you, for information and awareness, the final set of questions from the Oversight Group in respect of our Patient Safety Work Plan. Please find this attached at Annex A.

The question set has already been shared with Claire Pearce, as Executive Lead for this Work Plan, and will be subject to discussion at a meeting taking place on Thursday 28 July, also involving Dr Sharon Hilton-Christie and Paul Arbuckle.

Following the meeting, we expect to conclude and close off this Work Plan.

With my thanks and best wishes.

Fiona Lees

Chair, Independent Oversight and Assurance Grou on Tayside's Mental Health Services

Annex A

Patient safety work plan - final question set

The Oversight Group welcomed the opportunity to hear from colleagues when we met at the Murray Royal on 30 March. Thank for you providing us with your ‘Risk Management and Adverse Event Management’ (AEM) Policy.

We are looking forward to our next meeting on Thursday 28 July, when we hope to conclude matters. In advance of the meeting, we thought it would be helpful to set out the particular areas we would like to discuss.

Recommendations 11 and 31

We need a definitive number of outstanding SAERs accompanied with an expected timespan for completion.

In respect of the AEM Policy, it would be helpful to hear from you on the learning you highlight from adverse events in the Introduction to your Policy, specifically:

• as well as learning from when things do go wrong, there needs to be a clear focus on anticipating future risks and preventing safety problems occurring in the first place
• learning from when things go well should also be considered
• it is important to have mechanisms in place to ensure that the learning from these different sources is integrated and acted upon

Emphasis on learning and promoting good practice - please tell us how ‘near misses’ are reviewed regularly and can you give us any examples of system improvements you have put in place.

Openness about failures - in an anonymised way, could you share with us, any recent examples of where “patients, service users and their families are told what went wrong and why, and receive an apology for any harm that has occurred”.

In your Policy, you make clear in your objectives that reviews happen routinely and quickly, and adverse event reports increase as the organisation moves to a more open culture.  Could you please share with us what your management information is telling you in respect of these objectives?  Could you also provide us, in advance of our meeting, with the links to recent reports you have taken to Care Governance which advise on adverse event reviews, as per the definitions set out in your Policy?

We would like to hear from you on the progress you think you are making embedding the ‘collective leadership culture’ you describe within the Policy.

We require to see a written 'walk-through' of how the lessons acquired through completion of SAERs is (i) disseminated across the workforce, (ii) considered and absorbed by the workforce, (iii) consistently embedded in practice (iv) along with NHST's process which quality assures that these three elements are in place and operating, along with an assurance of the independence of the SAER assessor and how robust and rigorous the assessment has been.

You’ve shared with us that you have a number of adverse event reviews which have not been completed within the required timescales. At what stages are delays occurring, what are the reasons for these and what corrective action are you taking?

On feedback, closing the loop and sharing the learning - could you set out the specific arrangements you have put in place and how you take assurance that 1) they are being followed and 2) that they are effective.

In this regard, and relating to section 3.53 of Trust and Respect, it would be helpful to understand where NHST believes they now are in comparison to the 5% confidence of implementation of recommendations from SAERs stated in the original report together with a statement regarding the basis for the current assessment.

In the Policy at Appendix 4 (‘A Just Culture Guide’), could you confirm if this is applied as an integral part of your procedures?

At Appendix 6 (‘Policy Approval Checklist’), you report not having an implementation plan and further, that training would be available if requested. Both of these responses seem at odds when taken alongside the detailed work you have undertaken to implement new arrangements.

Protocol for use following Unexpected Death in Mental Health and Substance Misuse Services - it would be helpful if you could talk us through the application of this protocol.

In one of your initial ‘Vital Signs’ Briefings, reference is made to the weekly adverse events report distributed to teams - on an anonymised basis, it would be helpful to see an example.

In the same Briefing, reference is also made to the “downgrading” of events. Could you advise where oversight of this rests and of the instances of downgrading or indeed escalations.

Linked to the above question: what was the outcome of your January 2022 adverse event audit?

You also included a Timeline from 2019 to date, of the steps you have taken to put in place arrangements. When we meet, could you clarify for us, the respective roles and remits of:

• The SEAR Leadership Group
• The Adverse Event Review Leadership Group
• The Mental Health Services Quality and Performance Review Meeting
• The Integrated Leadership Risk Review Group
• The Safety Oversight Group
• The Weekly SEAR Group
• The Mental Health and Learning Disability SEAR Oversight Group

It may be that some of these groups have subsequently been stood down or superseded. Of those that continue to exist, do they align with the leadership levels set out in the Policy?

Recommendation 17

Tayside Executive Partners need to provide clarity in respect of which version of the Care Plan is to be taken forward for new cases and reviewed cases, where current non-complex cases become complex in the future. This is to ensure consistency across Tayside for patients

We need to see a written 'walk-through' regarding how the system is truly joined up with professional supervision for all staff.

The opportunity for significant system shift created by identifying circa 60% (75% in Perth and Kinross) patients not in the complex case category and therefore potentially not in need of CMHT provision exists. We also require to see from the TEP how this opportunity will be maximised, thereby creating better outcomes for patients and less dependency on formal services. 

Recommendation 19

No further information required. 

Recommendation 20

No further information required. However, in the final submission from the TEP to the Oversight Group in September, it would be important to include proposals for the sustainability of this programme / service.

Recommendation 22

No further information required. However, in our discussions with colleagues in Dundee HSCP, we were impressed to hear about the extent of the work undertaken in partnership with the Universities and the National Autistic Society and work with colleagues at Dundee and Angus College in support of student wellbeing. You should ensure that this work is fully reflected in the final submission from the TEP to the Oversight Group in September.

Recommendation 23

We require to see the data that is being routinely collated by NHST that demonstrates the positive impact of the implementation of the Improving Observation Protocol within inpatient units. In this respect, baseline data prior to the introduction of the protocol, would be of benefit.

Recommendation 27

No further information required. We have heard about usage of workforce planning tools to ensure that the staff establishments in each ward are correct. We have seen evidence in one ward of the planned expected and formal three times per week one-to-one engagement with patients and hear in the other wards that it is an issue that is constantly considered and planned for. We have also heard that the level of staffing in wards is such that there is significantly greater levels of one to one engagement with patients than three times per week, informal and by whoever is working on the ward at any time including by activities coordinators and bank/agency staff. It is the nature of life on a ward. The question is ‘to what end?’ There must necessarily be a relationship between the robust, sustained and fully embedded implementation of IOP (interaction and engagement) and one to one engagement, both of which ought to contribute to a positive impact on patients of their time in wards and corresponding reductions in length of stay. Further reflection on these aspects in the final submission from TEP would of value.

Recommendation 28

No further information required.

Recommendation 29

No further information required.

Recommendation 30

TEP reported to the Oversight Group on 24 January 2022 that evidence could be provided of progress to date and plans to continue the response to this recommendation. This remains outstanding and we require to see this evidence. In particular, the Listen, Learn, Change Progress Review Overview (June 2021) noted that 72% of the required 152 standards were being met. Please advise further on the matter being referred to here and in particular, what the remaining 28% gap represents and what action is being taken to close that gap.

Recommendations 37 and 46

We require a discussion with the Medical Director in regards to these recommendations and the totality of comments received by NHS Tayside reflected in the Scotland Deanery Quality Management Visit Report dated 8 and 9 November 2021.