Independent Oversight and Assurance Group on Tayside's Mental Health Services

Patient Safety Work Plan

85. This work plan brings together 14 recommendations from Trust and Respect, including Significant Adverse Event Reviews, anticipatory care planning, de-escalation, inpatient psychological services and support for junior doctors. This plan also includes the national Recommendation 32 for the Scottish Government, on the need for guidelines on substance misuse on inpatient wards.

86. We are grateful to all the people with lived and living experience and all the front-line staff who have given us their time and reflected their shared aspiration of ensuring that people in Tayside receive the safest and most beneficial care at the time they need it.

87. We have focused on the reviews of significant adverse events and safer care in inpatient wards, particularly in relation to de-escalation, ward-locking and complex case management.

88. We have commissioned a sample review of the Significant Adverse Event Reviews that have been completed since October 2021, carried out by Subject Matter Experts.

89. We welcome the progress that has undoubtedly been made in these important areas. There remains a need to be vigilant and to monitor the impact of the work undertaken to date to ensure it is making a difference to patients and their families. There is also a need to demonstrate that learning from each review is systemic and sustained.

90. We have been struck by the genuine commitment, passion and compassion of staff that we have met during our visits. We are encouraged by the way that de-escalation policy and practice has been embraced and we welcome the clarification of what constitutes complex need. The commitment to a continuous improvement approach is welcomed.

91. We have seen evidence that the inpatient wards are able to begin to demonstrate the positive impact of new ways of working that are person-centred and less medically orientated. There is always more to do, however, with the new leadership that is in place, momentum can be maintained if they are empowered to make changes

92. As we indicated in our third quarterly report, we have seen and heard much that is good and positively developing across Tayside in relation to the Patient Safety Work Plan recommendations. We have also noted that this tends to be in pockets of services and places. There is, therefore, still significant work to be done to ensure consistency of application of new and revised policies, practice and innovative models of provision (some of which are of national importance) across Tayside. This necessarily links to the effective functioning of the Integration Joint Boards and the need for genuinely collaborative and partnership working across all stakeholders in Tayside, including the Health Board and Councils.

93. We have heard examples from family members and carers with lived and living experience where provision continues to be less than satisfactory. Whilst most of this is of a historical nature and was reflected to Dr Strang in his evidence gathering for Trust and Respect, the fact that the issues of concern continue for these family members and has not been addressed by the Tayside Partners is an issue for us.

94. Some of the stories we have heard from family members and carers are not historical and as described to us, point to an experience that is not at a level that is either in keeping with the improvements introduced by Tayside in response to Trust and Respect or consistent with safe and protective standards of provision. It is incumbent on NHS Tayside to effectively listen to and hear these concerns and address them appropriately to ensure that patient safety for all patients is the primary outcome.

Recommendation 11

Ensure that the policy for conducting reviews of adverse events is understood and adhered to. Provide training for those involved where necessary. Ensure that learning is incorporated back into the organisation and leads to improved practice.

Context of Oversight Group assessment: An in-depth exploration of the robustness of whole system learning from events; the involvement of families and carers; openness about failures, closing the loop and sharing learning; and the protocol for reviews for unexpected deaths where mental health and substance abuse issues were present.

95. It is clear that significant work has been undertaken by the Tayside Executive Partners, and particularly by NHS Tayside, to demonstrate progress and change on this recommendation.

96. The Oversight Group has held very comprehensive and scrutinous discussions on several occasions with the Executive Director of Nursing, the Associate Medical Director Patient Safety, Clinical Governance and Risk, and colleagues, to fully understand the issues and the progress that is being made.

97. There are a small number of outstanding issues that Tayside Executive Partners did not address in their final submission, either individually or systemically. These include NHS Tayside bringing more transparency on the reporting of average timescale for completion of Significant Adverse Event Reviews, the number that exceed the expected completion timescales, and what happens in terms of near misses.

98. Nevertheless, NHS Tayside has come a long way during the course of our involvement. In June 2021, NHS Tayside was advised at its Board meeting that 'there is a comprehensive NHS Tayside adverse event policy with training available' and they RAG rated themselves as Green at that point. By November 2021, this had been revised to Amber. We were informed that a further updated process reinforcing clinical oversight to all mental health Significant Adverse Event Reviews, aligned to HIS requirements, was agreed at Executive Leadership Team in October 2021. In addition, in November 2021 the Clinical Governance team met with Health and Social Care Partnerships to agree processes to ensure implementation of new guidance consistently across Tayside.

99. The Oversight Group commissioned two independent Subject Matter Experts to review on our behalf those Significant Adverse Event Reviews that have been completed since the implementation of that new policy. Early in our engagement, we had been advised that the new policy had been rolled out from October 2021 and that there were 5 Significant Adverse Event Reviews completed since that time. It was these 5 Significant Adverse Event Reviews that the Subject Matter Experts reviewed.

100. The fully revised NHS Tayside Adverse Event Management Policy reflecting the Healthcare Improvement Scotland Framework was, however, only finally approved in March 2022. As such, the Subject Matter Experts noted that the 5 reviews that they considered had all been completed prior to the full introduction of the new policy. Their review highlighted a variability in the reviews presented in terms of style, tone, length and layout, but in the main, given the aspiration is one of a patient safety focus, this was present in all of the reviews along with a clear intention to identify good practice and to share areas to learn from.

101. They have advised that the Adverse Events Management Policy in Tayside is a thorough piece of work and sets out in detail a consistency of approach. The Subject Matter Experts considered all 5 reviews to be sufficient for the purposes of learning and improvement and would expect future reviews conducted under the revised policy to be more consistent going forward.

102. The Oversight Group consider that the work undertaken over the last 12 months to review and improve the approach to Significant Adverse Event Reviews means that Tayside is firmly heading in the right direction. NHS Tayside should be commended for the distance travelled on this issue. It is noteworthy that NHS Tayside has already asked to see the Subject Matter Experts report to address any points for learning.

103. The Subject Matter Experts recommend that NHS Tayside undertake its own review of the impact of the Adverse Event Management policy on mental health adverse event reviews in approximately one year's time, providing the organisation with assurance that the new policy is achieving what it is supposed to achieve. The remit given to, and report from, the Subject Matter Experts are included in Appendix 5 to this report.

104. Oversight Group RAG rate this recommendation Green.

Recommendation 17

Review all complex cases on the community mental health teams' caseloads. Ensure that all care plans are updated regularly and there are anticipatory care plans in place for individuals with complex/challenging presentations.

Context of Oversight Group assessment: The need to ensure that the most vulnerable patients receive the level of person-centred care that meets their needs.

105. Tayside has developed a clear definition of what constitutes a complex case. This is worthy of commendation and recognition as work of national importance that would be of value to all other Health Board areas to be aware of and apply.

106. There has been significant work undertaken by the Health and Social Care Partnerships to apply the new definition of 'complex case' that has been developed in response to Recommendation 17 and there is now clarity across the three areas as to the numbers of patients that are on the caseload for each Community Mental Health Team and within that, how many patients have conditions that are deemed to be complex. We have previously reported that the work undertaken on complex care definitions has provided the Tayside Partnerships with a strategic opportunity to contribute to a shifting of the balance of care in mental health services as it has identified that just 40% of the Community Mental Health Team caseloads in Angus and Dundee and only 25% in Perth and Kinross, are considered to be complex. This, in our opinion, creates an opportunity to be more creative for those non-complex patients who remain on Community Mental Health Team caseloads in the support arrangements made for them which needs to be considered by the Tayside Partnerships.

107. We have previously reported that NHS Tayside and its Health and Social Care Partnerships, operate seven different variations of a care plan, each of which broadly incorporates many of the areas for patient consideration that the HIS Anticipatory Care Plan (ACP) document contains. This could create confusion for staff and clinicians, but more importantly lead to a disparity of service provision to patients across Tayside. We have indicated that for all new patients deemed to be 'complex' - or for existing patients who are at a later stage reassessed as complex and who therefore should have in place an ACP-type document - NHS Tayside need to consider adopting just one of the seven care plans they currently use and apply it consistently across Tayside.

108. Tayside Executive Partners have advised that only in Perth and Kinross will there be a move to implement the Healthcare Improvement Scotland Anticipatory Care Plan in all new cases. We presume that this would also apply to individuals who may have an existing non-Anticipatory Care Plan and whose needs change at some stage in the future and their case becomes complex.

109. Tayside Executive Partners in their final submission to us did not commit to a timeframe of completion of Anticipatory Care Plans for all patients deemed to be complex, simply stating that 'we have some way to go before we can be confident that every person who is assessed as complex will have an Anticipatory Care Plan'.

110. The Oversight Group recognises the innovative work around the definition of complex cases. However, given the absence of a clear time bound plan for rolling out the new approach, we continue to assess progress on this recommendation as Amber.

Recommendation 19

Prioritise the development of safe and effective workflow management systems to reduce referral-to-assessment treatment waiting times. This should also include maximum waiting times for referrals.

Context of Oversight Group assessment: The need to ensure that patients receive the treatment they require at the earliest possible time thereby maximising the potential for recovery and improved wellbeing.

111. The Oversight Group has been presented with the monthly Community Mental Health Team data bundles and been advised about how they are being used at a local level, at least in Dundee. We have been advised that there has been Quality Improvement support to Team Leaders about how to use data but there is a view, confirmed by Tayside Executive Partners in their final submission, that the data needs to be more detailed than it is.

112. Tayside Executive Partners acknowledge that further work is required to achieve a dataset at the individual level, and that there has been in place an informal agreement on a 12-week access target which is not reported through any formal mechanism.

113. In the course of our engagement with stakeholders, we have heard a view expressed in the community that there continues to be waiting times for access to Community Mental Health Teams' support, and this is particularly the case for reviews of existing care plans, where medication regimes are in place.

114. There are therefore issues of pace (given the time since Trust and Respect was published) and transparency in relation to this recommendation.

115. Tayside Executive Partners believe that the summary of four actions that they describe as having been undertaken are sufficient to achieve the intended outcome. We believe that is optimistic.

116. The Oversight Group therefore believes an Amber RAG rating continues to be appropriate, particularly given the lack of narrative provided by Tayside Executive Partners about how they intend to get to a point that actions are complete and the intended outcomes have been achieved or actions are on track and the intended outcomes are very likely to be achieved in the timescales required.

Recommendation 20

Consider the development of a comprehensive Distress Brief Interventions training programme for all mental health staff and other key partners to improve pathways of care for individuals in acute distress.

Context of Oversight Group assessment: A recognition that not everyone who presents with acute distress requires to be either hospitalised or seen in a reactive crisis response service more likely to lead to an escalation of input from health services.

117. Significant work has been undertaken by the Tayside Partnership to implement a Distress Brief Intervention approach consistently across Tayside. This is to be commended.

118. Following an open tendering process, which included a comprehensive service specification detailing service delivery requirement and training for existing staff across Tayside, a provider has been in place since the end of 2021.

119. The Oversight Group, in discussion with colleagues, has indicated that there is a need for Key Performance Indicators to be developed for this service.

120. We have also indicated that there is a need for clarity on sustainability of the provision and note that this is a further action to which Tayside Executive Partners have committed.

121. The Oversight Group consider that a RAG rating of Green is appropriate.

Recommendation 22

Develop clear pathways of referral to and from university mental health services and the crisis resolution home treatment team.

Context of Oversight Group assessment: A recognition of the fact that young people leaving the security of their home for the first time are particularly susceptible to anxiety and challenges to their mental health and wellbeing and require support in this.

122. NHS Tayside Health Board were informed in June 2021 that 'clearly defined pathways have been developed and implemented with both universities'. The pathway was tested and refined throughout 2021 which proved challenging due to Covid-19. We have been advised that during lockdown, students from overseas or whose homes were other than Dundee, who became known to the services were encouraged to engage with their local care provider. Tayside Executive Partners in their final submission advised that the pathway went live in May 2022.

123. We welcomed the opportunity to meet with colleagues from Abertay University's Counselling and Mental Health Service, and Dundee University's Mental Health Support Service. This project has been led by NHS Tayside in partnership with both universities and the Crisis Resolution Home Treatment Team.

124. We were impressed by the comprehensive processes put in place in support of this recommendation and specifically the priorities they had set for pathways for students. We appreciated learning more about the work of the respective university teams to better understand the needs of their students and to develop person centred support. In circumstances where there is an emergency, a robust pathway has been put in place which was tested prior to its launch.

125. This pathway is there to be used in exceptional circumstances with the emphasis placed on early intervention and prevention. Whilst the number of referrals may be low, there is a high level of confidence in the integrity and effectiveness of the process that has been put in place.

126. The project team has put in place arrangements for student feedback and review which include hearing from students on their experience, learning about the impact of the referral process and identifying any unintended consequences. Colleagues from both universities were positive about the links they have put in place with the Crisis Resolution Home Treatment Team and signalled their intention to develop similar close working with community mental health teams.

127. During the meeting, we also heard about the difficulties which can arise when students who are in Dundee, away from home, have been unable to register with local GPs due to closed lists. We welcomed the opportunity to talk to the Chair of the Area Clinical Forum about this when we met. The shared endeavour between the universities and NHS Tayside to ensure that students are able to get help when they need it, was very evident from our discussions.

128. Finally, we simply note we were surprised to see no reference by Tayside Executive Partners to some very significant work being undertaken locally by Dundee Health and Social Care Partnership and the universities to support students with Autism Spectrum Disorder.

129. This recommendation has been addressed and a Green RAG rating is appropriate.

Recommendation 23

Develop a cultural shift within inpatient services to focus on de-escalation, ensuring all staff are trained for their roles and responsibilities.

Context of Oversight Group assessment: The importance of ensuring that any stay in inpatient wards requires to be as safe as it can be for all patients and is therapeutically improving wellbeing. It also needs to be a safe environment for medical and clinical staff to work in.

130. The key element of the response to this recommendation has been the comprehensive introduction and implementation of the Improving Observation Practice protocol across the inpatient wards.

131. The Oversight Group has heard from staff in the wards about the positive impacts for patients and on their own practice, of this new approach. We are encouraged by the way that de-escalation policy and practice has been embraced within the inpatient units. We have seen evidence that the inpatient wards are able to begin to demonstrate the positive impact of new ways of working that are person-centred and less medically orientated.

132. We have been provided with sample datasets for restraint and violence at work for wards 1 and 2, Mulberry units in Carseview, Moredun in Perth Royal, Strathmartine and the Learning Disability Unit at Carseview.

133. This information is not in the public domain and is for local management information purposes only. Having considered this data in isolation, it is difficult to know whether the trends that are shown in the dataset represent good performance or not. NHS Tayside have advised us that they have had access to national benchmarking datasets included in which are datasets relating to restraint since October.

134. We acknowledge and welcome the comments that Tayside Executive Partners make in their final submission. The submission states, 'we know that we will need to constantly attend to ward based cultures through robust governance, leadership, local data, harm data, external visits and the experiences of staff and patients'.

135. In the course of our work, we have had a number of unsolicited approaches from individuals with lived and living experience of the inpatient system. Some of the stories we have heard from family members and carers are not historical and point to an experience that is not at a level that is either in keeping with the improvements introduced by Tayside in response to Trust and Respect, or consistent with safe and protective standards of provision. In this context, it is important that Tayside Executive Partners have made the statement that they have and respond appropriately in every instance.

136. By way of example, in response to a request from the Oversight Group for assurance in respect of the undertaking and recording of risk assessments, we have been provided with an updated Clinical Risk Assessment and Management Plan Protocol, due to be reviewed again in December 2022. This protocol provides guidance for completion of risk assessment documentation and associated timelines by trained staff. The robust endeavour by NHS Tayside on this issue has been a direct response to issues of concern raised with us in one such unsolicited approach.

137. Given the good work on the observation protocol, on balance, the Oversight Group's assessment is a RAG rating of Green. In doing so, we stress the critical importance of Tayside listening to the experience of patients and families and the need for vigilance and continuous improvement.

Recommendation 27

Provide adequate staffing levels to allow time for one-to-one engagement.

Context of Oversight Group assessment: Tayside Executive Partners' original intended outcome to this recommendation was mechanistic and process driven, rather than focussing on the benefit to patients of one-to-one therapeutic engagement.

138. We indicated in our final question set to Tayside Executive Partners that 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 heard in the other wards that it is an issue that is constantly considered and planned for.

139. We have also heard that the level of staffing in wards is such that there are 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.

140. The question is 'to what end?' There must necessarily be a relationship between the robust, sustained and fully embedded implementation of Improving Observation Practice (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.

141. Appropriately, there is a significant emphasis in Tayside Executive Partners' assessment of progress on the need for continuity, whilst elsewhere in their response they acknowledge that 'we are aware of the constant change within Nursing Teams as staff leave to take up new opportunities'. In terms of further proposed action, they are progressing with the recruitment of 27 Newly Qualified Practitioners from September/October onwards and they acknowledge the continued use of nurse bank, overtime and agency staff to make up gaps in rotas.

142. In reflecting on the original intended outcomes of their endeavours on this recommendation, Tayside Executive Partners have indicated that their intended outcome is 'staffing levels will enable one to one engagement with patients to take place'.

143. Sufficient staffing levels are of course critically important, but the numbers themselves should be viewed as a means to an end, not an end in themselves. We are of the view that more attention could have been given in this recommendation to making the connection to quality and the impact on patient recovery and wellbeing that the available staff are having. Our RAG rating therefore remains at Amber.

Recommendation 28

Ensure appropriate psychological therapies and other therapies are available for inpatients.

Context of Oversight Group assessment: To provide the widest range of support available to patients in inpatient wards to achieve person-centred care and maximise recovery potential.

144. It is clear that NHS Tayside has experienced very real challenges in progressing this recommendation since Trust and Respect was published. This is in part due to a shortage of availability of clinical psychologists in Scotland, resulting in several unsuccessful attempts to recruit to this level of post in Tayside. This was followed by a revision of the plan to create a consultant psychology post, which is still awaiting job matching under Agenda for Change, after which all other new posts will be recruited.

145. In their final submission to us, Tayside Executive Partners separately state in their understanding of this recommendation that 'the added value of psychology to inpatient settings is well recognised', while later commenting that, 'it should be noted that the evidence base for inpatient psychological therapies is relatively weak at present'. It is commendable that despite the evidence being relatively weak, professional and clinical guidance endorses the use of psychological therapies within inpatient settings.

146. It is to the credit of Tayside Executive Partners that they have recognised that the position in regard to psychological therapies and response to this recommendation is not where they had reported to NHS Tayside's Board in June 2021 when they RAG rated as Green, primarily based on an exclusive focus on trauma-informed training and provision. Important though that is, it is clearly only a part of the range of psychological therapies that ought to be available to patients in wards.

147. The Oversight Group also notes the role of Dundee City Integration Joint Board as lead partner for psychological therapies as set out in the revised Integration Schemes. This is not a new responsibility for that Integration Joint Board, but it is noteworthy that it was as recently as February 2022, that the Integration Joint Board was presented with a Psychological Therapy Services Strategic Update paper in which the Board was asked to approve the proposal to develop a Psychological Therapies Strategic and Commissioning Plan for the first time in Tayside.

148. Our view is that this remains a somewhat confused landscape, although there is now a high-level plan in place. However, Tayside Executive Partners are indicating that it will take up to two years to realise, meaning that it will be almost five years since the publication of Trust and Respect. For that reason, we believe an Amber RAG continues to be appropriate.

Recommendation 29

Reduce the levels of ward locking in line with Mental Welfare Commission for Scotland guidelines.

Context of Oversight Group assessment: In earlier assessments from Tayside Executive Partners, NHS Tayside's initial focus on this recommendation was process driven and focussed on updating guidance, when it is clearly about issues of deprivation of liberty and maintaining patient safety.

149. We have visited all the inpatient wards during the course of our work and have observed the practice relating to ward locking. We have consistently heard from staff that the issue of ward locking is continuously risk assessed and is both individual and ward dynamic based. The latter is made complex in the GAP wards by the mix of patients in wards, for which the clinical rationale is that all the patients have been deemed to require inpatient care. Wards are notionally based on geography, serving particular areas (although in reality all wards had patients from each of the Council areas within them). All wards were mixed gender, high numbers, mixed basis for residence (compulsory and informal), mixed age from young adults. Clinicians spoke to us about the need, in exceptional circumstances, to admit teenagers at a weekend. They commented on the prompt and effective response from Child and Adolescent Mental Health Services to move a young person on to the dedicated inpatient unit at Dudhope.

150. The good practice that we witnessed on ward locking also necessarily considered the limitations of the environment in Carseview. There is no doubt that the main door into many and sometimes all of the wards is locked for lengthy periods of time in an effort to effectively balance safety, security and freedom. In our opinion, ward staff are doing as much as they can on this issue within the limitations in which they operate.

151. We assess a RAG rating of Green on this recommendation. Again, we would stress the importance of Tayside Executive Partners' acknowledgement, contained within their final submission, that there will always be a requirement for ongoing audit of this issue and the practice in wards therein.

Recommendation 30

Ensure all inpatient facilities meet best practice guidelines for patient safety.

Context of Oversight Group assessment: The contribution that a safe and comfortable environment makes in aiding the recovery of patients in need of an inpatient admission.

152. Tayside Executive Partners in their final submission evidence that extensive refurbishment and environmental safety works have been carried out across much of the inpatient estate following significant investment. Included in this has been £1.6m of expenditure on Ligature Anchor Point Risk Reduction works in 2020/21 and 2021/22. The work by NHS Tayside on the environmental safety aspects within their wards is noted.

153. In their final submission, Tayside Executive Partners reference the quality of the care environment as having a key role in supporting an individual's recovery and recognise that this is presently variable across the main hospital sites. There has been a focus on improving safety within all wards which has been influenced by lessons learned from adverse events. There is a recognition that there needs to be an equal focus on the comfort and aesthetic of the environment to promote wellbeing and recovery and they have set out plans for further investment through Integration Joint Board allocations for this purpose.

154. As part of their response to the Independent Inquiry, NHS Tayside set out within the Listen Learn Change Action Plan, the work they were taking forward in pursuit of the Royal College of Psychiatry Accreditation and reported to the Health Board in June 2021, that as a result of a Peer Review Accreditation visit in January 2021 to the Intensive Psychiatric Care Unit, 72% of 152 psychiatric standards were considered as being met. In the same report, the Health Board was advised that all General Adult Psychiatry Admission Wards were either actively engaged in the programme or preparing to take part.

155. In January 2022, Tayside Executive Partners indicated that evidence could be provided of progress to date and plans to continue the response to this recommendation. The Oversight Group wished to understand what still required to be done in terms of achieving accreditation. This remained outstanding at the point of our final question set and we asked to see this evidence. In particular, we asked what the remaining 28% gap represents and what action is being taken to close that gap.

156. Tayside Executive Partners have been unable to provide this detail, stating instead that only a further 12 of the outstanding 31 recommendations from January 2021 have been completed and that work on the remaining 21 is 'continuing'. As such, we have no sense of what they still have to do. In terms of further action proposed, in respect of the environment, the only 2 actions related to recommendation 30, are the upgrade of en-suite facilities at Mulberry and new bedroom furniture.

157. Finally, we note NHS Tayside's intention to revisit the benefits of accreditation through the Royal College of Psychiatry in the light of the development of national standards for secondary mental health services in Scotland.

158. The Oversight Group RAG rate this recommendation as Amber.

Recommendation 31

Ensure swift (timeous) and comprehensive learning from reviews following adverse events on wards.

Context of Oversight Group assessment: There is a clear link between this recommendation and Recommendation 11.

159. As indicated in our consideration of Recommendation 11, it is clear that significant work has been undertaken by the Tayside Partnership and particularly by NHS Tayside to deliver tangible progress on this recommendation.

160. Tayside Executive Partners have set out in detail in their final submission the actions that have been taken alongside the review and development of the revised Adverse Events Management policy, to ensure comprehensive learning from reviews going forward. They have also set out the range of routes that they take to ensure as wide a dissemination of learning across the workforce as is possible.

161. These are commendable steps forward from where Tayside were in March, when we were provided with an example of a 'flash report' as being one of the means of disseminating learning at that point.

162. Many of the approaches being deployed by NHS Tayside to share learning, including Team Based Quality Reviews and the clinical governance structures put in place with the revised policy, are very recent. However, the Subject Matter Experts engaged specifically by the Oversight Group to review 5 Significant Adverse Event Reviews, have noted that there is evidence of both intent and plans to feedback to staff and the wider organisation, regarding findings and conclusions.

163. We have encountered several situations where the experience of Significant Adverse Events Reviews has not been a positive one for the families involved. They have been left with many unanswered questions and a burning desire to ensure that their experience is not repeated elsewhere. We have also heard that the process can still feel impersonalised, with poor levels of engagement and involvement in the Significant Adverse Event Review process and what has been perceived by families as a tick-box exercise. In essence, what has been described to us is a process that leaves a feeling of being a learning point for the Health Board and begs a question as to why change isn't taking place that prevents significant adverse events from happening. We consider that families and relatives who are participating in a Significant Adverse Event Review need to have access to support. This goes beyond engagement in the process and NHS Tayside should consider how this could be offered. Significant adverse events will regrettably happen from time to time and why they occur needs to be understood, but the experiences outlined need to be properly heard by the Tayside Executive Partners to ensure that confidence in the new policy and its application, is as widespread as is possible.

164. The Oversight Group has RAG rated this recommendation as Green. However, this does not mean that the action is complete. This is one of those areas of activity that requires ongoing and continuous intentional endeavour to ensure that learning continues to be spread and taken on by the relevant staff across Tayside.

Recommendation 32

A national review of the guidelines for responding to substance misuse on inpatient wards is required.

Context of Oversight Group assessment: There are at present no national guidelines for responding to substance use on mental health inpatient wards. Medical and clinical staff therefore have no standardised approach to ensuring the wellbeing and safety of patients or staff where substance misuse is occurring.

165. Scottish Government officials advise in their final submission to the Oversight Group (Appendix 4) that a Short-Life Working Group has developed draft guidelines which are due to be signed off by the Minister for Mental Wellbeing and Social Care. In January 2023, there will be a 4-week test period of implementation in two inpatient sites in Scotland. National implementation will follow between February and April 2023. There will be an assessment on how the guidance is working in practice thereafter throughout 2023.

166. It is positive that there are draft guidelines now available, developed by a multi-agency Short-Life Working Group. We would, however, have expected to see the trade unions being involved in the group. Consultation will clearly be necessary in any forthcoming rollout.

167. The Oversight Group's concern, however, is the pace and direction on which this recommendation has been progressed. Contrary to Dr Strang's expectation set out in the recommendation there were no guidelines to review, so the task has been to develop guidelines and implement them.

168. We have questioned the need for the 4-week test period and suggested that the guidelines could and should be fully implemented as soon as possible particularly given the time-lapse since Trust and Respect. Any amendment and adjustment that may be required, could easily be undertaken within the review mechanism indicated in the further action proposed by Scottish Government.

169. The Oversight Group RAG rate this recommendation Amber.

Recommendation 37

Support junior doctors who are working on-call and dealing with young people's mental health issues.

Context of Oversight Group assessment: Inpatient provision is dependent on junior doctors and in respect of children and young people's mental health issues, there needs to be confidence in the arrangements in place that such key personnel are supported and equipped to undertake their duties.

170. In their final submission to the Oversight Group, Tayside Executive Partners have outlined the actions that have been taken in response to this recommendation. In demonstrating progress to date, they have cited the Deanery reports that have been provided to them since the publication of Trust and Respect.

171. The Oversight Group has considered the most recent report from November 2021 and subsequently had detailed discussions with the Operational Medical Director for Mental Health and Learning Disability, along with the recently appointed Medical Director for NHS Tayside.

172. The Scotland Deanery Quality Management Visit made to NHS Tayside in November 2021 reported that they were provided with the same overview of support that the Oversight Group has been provided with up to and including Tayside Executive Partners' final submission. This is essentially that there is a tiered level of on-call support up to consultant level available to all trainee doctors. We have been advised by Tayside Executive Partners that they have received verbal and intermediate written feedback from the Deanery for this year's Autumn visit, which is reported to demonstrate considerable improvements made in all of these areas. At the time of writing, this has not been made available to us, however, it is a welcome update.

173. All levels of trainee doctors reported to the Deanery that they knew who to contact and by and large, where they were able to access support and advice during on-call periods. There were issues of occasional Wi-Fi connectivity impacting at times on access reported by trainee doctors, particularly at Murray Royal and sometimes at Carseview.

174. A bleeper system has been put in place to mitigate the Wi-Fi connectivity issues in the short term, but it has been clear from our meetings that at Murray Royal, this remains a substantive issue. This is despite the Deanery indicating that this required immediate action in November 2021.

175. While it is possible that a young person may need to be treated at Murray Royal on an emergency basis over a weekend, the connectivity issue does not impact on junior doctors in Child and Adolescent Mental Health Services inpatient provision.

176. Tayside Executive Partners recognise in their final submission that the clock is reset with every new junior doctor rotation and accordingly, the importance of a continuing programme of induction, awareness raising of support arrangements including for on-call, learning and development is a continuous and ongoing cycle. The recommendation has been addressed and the Oversight Group assess a RAG rating of Green.

Recommendation 46

Encourage, nurture and support junior doctors and other newly qualified practitioners who are vulnerable groups of staff on whom the service currently depends.

Context of Oversight Group assessment: There needs to be confidence in the arrangements in place that junior doctors and other vulnerable groups of staff are properly supported and equipped to undertake their duties. The report from the Scotland Deanery Quality Management Visit, dated November 2021, highlighted that there was much to do in respect of ensuring support for staff.

177. NHS Tayside has demonstrated to the Oversight Group that an extensive range of learning and development opportunities are available for all NHS Tayside employees covering specialist topics and also generic organisational and values-based programmes.

178. It is, however, less clear how much learning and development is being taken up by newly qualified practitioners. We have been advised that all Junior Medical Staff are required to attend the mandatory induction arrangements. However, the Oversight Group has not seen in one place, a comprehensive annual or rotational programme of induction and training that is mandatory and/or developmental. We might expect this to includes numbers of the various grades of newly qualified practitioners who are eligible for learning and development, with percentage levels of attendance and completion of the learning that is available. We would have expected such data and analysis to have been available, particularly in light of comments made to the Deanery about some trainees not being able to access induction training.

179. In their visit in November 2021, the Deanery noted that trainees value the Thursday teaching sessions referenced by the Tayside Executive Partners.

180. However, the Deanery also noted the following points for refection and improvement:

• Training provided for GP trainees required to be reviewed across the sites to ensure consistency and compliance with the GP curricular requirements.
• The trainee buddy system to provide cross cover did not support attendance at formal departmental and specialty teaching and required to be reviewed.
• Core trainees in Carseview Centre continued to undertake significant amounts of non-educational tasks resulting in little psychiatry training. This was an issue raised by the Deanery in their previous visits in 2019 and 2020.
• There was a need to review and respond to the issues raised by senior trainees regarding their rota, including concerns about wellbeing and safety.
• There was a need to roster educational sessions so that core trainees and GP trainees do not need to arrange cover to attend educational sessions.

181. The Oversight Group acknowledges the significant measures that NHS Tayside have put in place to ensure the encouragement, nurturing and support of junior doctors and other newly qualified practitioners. However, we have not seen robust data regarding take-up, nor structural responses to the points raised by the Deanery.

182. As such, the Oversight Group considers this recommendation to be RAG rated Amber.