An independent investigation into the care and treatment of Christie in West Lane Hospital by Tees, Esk and Wear Valleys NHS Foundation Trust

The report

We understand that reading these reports may cause you to feel worried, upset or angry.

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If you’re not in crisis but want to talk to someone about how you’re feeling or to ask any questions please email us at tewv.enquiries@nhs.net. A senior clinician can arrange to call you or answer your questions by email – someone will be available between 9am and 5pm up to Friday 4 November.

TEWV response to NHS England independent investigation Christie Harnett

Tees, Esk and Wear Valleys NHS Foundation Trust response to the recommendations that arose from the Niche Health and Social Care Consulting independent investigation (CH)

The following assurance statements have been produced as a response to the Niche independent investigation into the care and treatment of (CH) in Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and Cumbria, Northumberland, Tyne, and Wear NHS Foundation Trust (CNTW)

The independent investigation made a total of 22 recommendations.

This section addresses recommendations 1, 2, 6, 7, 8, 13, 17, 18, 20, and 21, in order as made by the report.

Recommendation number 5, 11, 14, 15, 16, 19, 22, and relate to other organisations and are therefore not included in these assurance statements.

Recommendation 3, 4, and 12 was made jointly with TEWV, and CNTW. This statement provides only the TEWV response. Recommendation 9 and 10 is a joint recommendation for the Local Authority and Health Providers. This statement provides only the TEWV response.

Introduction

We would like to apologise unreservedly for the unacceptable failings in the care of Christie which the report clearly identifies.

We accept in full the recommendations made in the report – all the improvements required are being made where applicable to our services.

TEWV has not delivered CAMHS inpatient services since September 2019. CNTW provides these inpatient services to children and young people from the West Lane Hospital site – this arrangement was formally put in place NHS England in September 2020 and opened to admissions in April 2021.

Following a governance review in March 2021, and a comprehensive public engagement exercise that followed, a new TEWV organisational and governance structure was put in place from 1 April 2022 with simplified governance processes and strengthened reporting from teams through two new care groups directly to the Trust’s Board, embedding increased line of sight and oversight from ward to Board.

As part of this, we have recruited two lived experience directors into our leadership team to make sure the patient voice is heard at the very highest level in the organisation.

Importantly, all the necessary changes are being made to the services we deliver, with the knowledge and oversight of the CQC and NHS England and reviewed by them monthly at an external Quality Assurance Board, chaired by NHS England.

In the three years since these tragedies, we’ve made significant improvements – how we assess the risks to our patients, how we organise and staff our services, and how we more closely involve the families and loved ones themselves.

These improvements are being delivered through our five-year change programme “Our Journey to Change”, which sets out why we do what we do, driven by three big goals to create a great experience for our patients, carers and their families, for our staff, and for our partners.

This includes an unrelenting focus on patient safety, with clear priorities set out in our patient safety strategy – this is our absolute priority.

This is supported by a quality assurance programme, and our quantitative and qualitative data shows that we have made considerable progress, and these are continually measured, evaluated, and reported upon.

We have completely overhauled the community services we provide to young people in Child and Adolescent Mental Health Services (CAMHS) to provide safe and kind care, today and every day.

Improvements we have made in CAMHS have been acknowledged by the CQC in a recent inspection, where services had improved – they said our senior management team had responded promptly to address issues identified at the previous inspection – we recognise there is still work to do, however we are moving in the right direction.

We are working hard to put patients and carers at the centre of everything we do – treating everyone with respect and compassion and taking responsibility for our actions.

These assurance statements outline the improvements we have made in response to the report recommendations.

Overarching context

To provide additional and important context, the following information provides details about service developments that have been underway within TEWV CAMHS over the last few years. This demonstrates that specific recommendations have been considered and acted upon and provides additional assurance regarding the fundamental changes to our services that are underway.

Service development work has been undertaken in CAMHS to improve care for young people and their families and carers. This began with a detailed analysis of the data based on different levels of need. This included the development of principles of care for people with the most complex presentations which include specific guidance for multi-agency and multi-disciplinary working.

During 2021-22 a significant programme of work got underway to develop evidence-based pathways of care using what’s known as the iTHRIVE system framework, which is recognised nationally as a way of promoting good practice. These pathways follow evidence-based National Institute for Clinical Excellence (NICE) guidance and have been developed by staff using the available evidence base and clinical expertise. Pathways include guidance on assessment, formulation, re-formulation, treatment approaches and care planning, with shared decision making considered with children, young people and their families and carers. All pathways include guidance for any adjustments which may need to be made for autistic people.

These new clinical pathways are due to be launched in November 2022 with a clear plan for evaluation, review and continual improvement.  

Recommendation 1

Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) must provide significant assurance to the Trust Board and its commissioners that it has a robust environmental and ligature risk assessment process and the ability to respond effectively and urgently to mitigate risks identified through this process.

TEWV response:

The Trust has undertaken a comprehensive ligature reduction programme across its inpatient services since 2019, and this programme continues to date in both a planned way and in response to emerging risks or themes from incidents and national alerts. We have invested over £5m in this programme since 2019, with a further £2.8m due for completion by March 2023.

In January 2020, a Trust-wide environmental risk group, was established with executive level oversight to agree service standards, oversee the estates works delivery programme and report on progress.

The role of the group is to assist the Trust in its management of patient safety through the oversight and management of environmental risks. The group has specifically strengthened systems and processes for identifying and reporting environmental risks and deficiencies, including emerging risks identified from themes, and trends from incidents. A report from the group outlining work completed as well as planned work went to the Trust’s Quality and Assurance Committee (a Board sub-committee) in May 2022, providing assurance on the work undertaken to date. We have also invested in assistive technology called Oxevision, which has been installed in a number of wards. This system supports clinical teams and enhances patient safety by using contact free, vision-based monitoring technology to monitor a patient’s vital signs and high-risk activity. This offers safe and unobtrusive care, which is respectful of people’s privacy, and we are developing and evaluating our services to ensure we embrace the benefits of this assistive technology.

The group meet monthly to review the work programme, and a monthly ligature incident data from the Datix system is reported, including anchored ligatures identified of greatest risk. The group membership includes representatives from the Trust’s estates and facilities department, infection, prevention and control team (IPC), compliance team, as well as clinicians and managers representing our care groups. Advice and agreement are sought from the service development groups on replacements and standards across specialties as required.

Following the publication of a national alert to review all policies in relation to low level ligature risks, the Trust’s Suicide Prevention Environmental Survey and Risk Assess Procedure (our ligature risk assessment process), was reviewed and updated in October 2020. This procedure strengthens our ability to respond effectively and urgently mitigate identified risks. The survey is conducted annually to identify any Trust fixtures and fittings, materials and equipment which may pose a risk of self-harm. The procedure covers the Trust’s formal approach to ligature reduction and has minimum standards in place to reduce harm within inpatient settings. Timeliness of completion of surveys and actions taken are monitored through the environmental risk group alongside incident data to ensure risks are effectively mitigated in a timely way.

In line with The Samaritan’s media guidelines for reporting on suicide, the Trust will not publish any further information on the specific nature of this work.

Recommendations 2, 4 and 7 -have been combined – responses are outlined below and should be considered together.

Recommendation 2

TEWV must ensure that risk assessments for young people in child and adolescent mental health services (CAMHS) are based on a psychological formulation and a full understanding of the longitudinal patterns and instances of harm, and where possible are developed by a multidisciplinary team (MDT) in conjunction with the young person and their family.

TEWV response:

The Trust has developed new safety summary and safety plan documents. These support a psychological formulation approach to risk assessment with children, young people, their families and carers. The documents require a consideration of a young person’s history regarding what has happened to them, and any patterns to help understand when they have been better or become more unwell. The risk assessment and management plans need to be developed alongside a thorough understanding of the young person within their context. Risks of harm to self and others are considered including where there are younger siblings present in the family. This forms an integral aspect of care planning building on the assessment, formulation and shared decision-making process described above and includes consideration of risk to others. Safeguarding policies are followed where required.

These were introduced into CAMHS in April 2021. Our Quality Assurance Programme currently shows that 96.8% of children in treatment have a safety summary and safety plan in place across the Trust. We continue to work with clinicians to enhance the quality and have established processes to support this via caseload supervision, clinical supervision and daily discussions (huddles). We have assurance processes including fundamental standards and peer reviews to ensure clinicians have a variety of sources of support.

Recommendation 4

TEWV and CNTW must ensure that plans of care for young people in CAMHS incorporate evidence-based practice.

Recommendation 7

TEWV must ensure that care plans are written so that they are clear, patient-centred, easy to understand and follow, and guide staff to care for the young person based on the assessment of all needs and risks.

TEWV response 4 & 7 combined:

Alongside the developments described above, the work around care planning continues to be a priority and is overseen by the Quality and Safety Programme Board as well as the Clinical Strategy Board.

Significant work has been undertaken over the past 18 months to make sure care plans are developed with a young person and their family or carer, and that these are trauma-informed, recovery-focused, autism aware and meaningful for the children and young people themselves. The Trust is working hard to progress this as quickly as possible, with the programme of work subject to ongoing review and evaluation.

To make sure care plans developed for young people in CAMHS include evidence-based practice, we use what is known as a 5P formulation structure, to organise assessment information when children and young people come into the service. The 5Ps are: current Presentation, Pre-existing, triggers for current issue (Precipitating), any maintaining (Perpetuating) factors, and the Positives to understand what is going well. The 5P formulation structure is a standard format utilised in mental health services nationwide approved by the British Psychological Society.

We have found that this is a useful way of organising information and for children, young people and their families and carers, to develop a shared understanding and language with the clinical staff, to make sure it was patient-centred and easy to follow, and that the care plans are completed together in way which the young person and their parent / carer also understands.

Using this method to assess people, means decisions about an individual’s care is made with them and their family or carers. We have often received feedback from people who use our services that they don’t like having to repeat their stories. Developing a shared 5P formulation also helps with consistency for sharing relevant information and avoid having to do this.

In addition to the above, a quality improvement event was held in March 2022 to focus on the clinical model of care planning across the Trust. The event was well attended by people we support in our services, carers, professionals from across the Trust’s geographical area

Consensus from the event was that care planning must be owned by the patient and contributed to by the care network involved in a person’s care.

Outcomes from the event included additional training sessions which took place in April and May 2022 to make sure staff have the appropriate skills to co-create meaningful, goal-orientated care plans. Awareness sessions were arranged for people we support in our services, carers, and our partners to facilitate a shared understanding of the changes. The event also looked at which parts of the care plan review could be stopped to reduce duplication and free up staff time to care.

The introduction of the Trust’s new electronic patient record system will also enhance the care planning process.

Recommendation 3

TEWV and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) must ensure that any young person with a recent history of self-ligature has a written care plan that identifies how staff (or families in the case of a community setting) are to care for the young person and mitigate the risks of fatal self-ligature.

TEWV response:

As the Trust no longer provides inpatient services for children and young people, our response is focused on community services. In the community, staff would not be caring for young people directly. Therefore, it is standard practice for community CAMHS to make sure parents / carers are advised how to provide close supervision for young people who are at risk of self-harm, including self-ligature, to maximise safety. This is routinely recorded in the risk assessment documents (safety summary and safety plan). Daily supervision and consultation are available for staff where required.

Recommendation 6

TEWV must ensure that decisions about observation levels are clearly recorded and that all interventions are clearly documented.

TEWV response:

To strengthen the recording of mental health observations, the Trust’s policy around supportive observation and engagement was reviewed in December 2020. A new competency-based assessment was introduced for all clinical staff prior to the policy going live, to make sure staff understood it and what was required of them.

In January 2021, the Trust held a five-day quality improvement event to make sure robust systems were in place to assess and mitigate patient risk, including the management of observations and observation levels. The aim was to develop a simplified and streamlined framework to enable effective assessment, risk assessment, care planning and care delivery.

The outcome was a ‘plan on a page’ framework, which simplified the electronic patient record in the form of the safety summary and safety plan, leave plan, observation plan and care plan.

Staff took part in training sessions to recognise and understand:

• areas of harm and the need to take immediate action,
• working collaboratively with the multi-disciplinary team (MDT) and the patient when determining observation levels,
• how to review static and dynamic risk factors that may affect potential harms,
• the importance of maintaining simultaneous records, and;
• clarity of roles and responsibilities in relation to observation levels

Clinical risk assessment and management guidance was provided to clinical staff to support their practice in line with the Trust’s revised Harm Minimisation policy (clinical risk assessment and management). MDT huddles were introduced in inpatient areas and outcomes are now recorded in clinical records. This includes discussion on observation levels. Following this, a quality assurance (QA) programme was introduced and includes the following:

• Assurance self-declaration: a fortnightly assurance tool reviewing all patients on inpatient wards. The tool monitors compliance with completion and updating of safety summaries, safety plans, incident reporting, leave and observation plans as well as associated documentation. The tool was updated on 23 October 2021 to provide a more focused and detailed review of the quality of patient records and clinical record keeping.
• Modern matron quality review: a monthly review of quality indicators and information in inpatient areas. It includes 33 standards relating to safety summaries, safety plans, patient carer involvement, leave plans, and observations plans. Each ward or team have developed continuous improvement plans based on intelligence gathering from reviews and case note reviews.
• Practice development review: a monthly assurance tool led by the practice development team. The practice development practitioners (PDPs) observe MDT discussions in relation to risk, leave, level of observations, mental state, medication compliance and effectiveness of medication regime and whether everyone in the MDT is felt to have a voice. PDPs now work with staff across both inpatient and community services focusing on completing robust risk assessments and ensuring the quality of mental state examinations and record keeping, including observation levels.

The quality assurance programme has provided evidence that observation and engagement plans, for both day and night, were present in 99% of cases. It also showed that patient observation levels documented in the clinical records matched the paper sheets and visual control board. There was 100% compliance with allocation sheets being fully completed, specifying the named member of staff responsible for carrying out observation and engagement for each specified time-period.

Recommendation 8

TEWV must ensure that trauma-informed therapy is a routine aspect of a young person’s care provision where there are any considerations of previous trauma, not just diagnosed post-traumatic stress disorder (PTSD), and that there are sufficient staff with the requisite skills to provide this.

TEWV response:

To address this recommendation, we have approached this in two parts; trauma informed approaches to care and trauma focused therapeutic approaches.

Trauma Informed Approaches

CAMHS adopts trauma informed approaches (TIA) across our services, where we guide staff to consider what may have happened, or be happening, in someone’s life to understand why they are presenting in distress. As part of Trust-wide developments, there has been a CAMHS training programme on trauma informed care (TIC) for all staff, including clinical, managerial and administrative colleagues. Training was developed using the evidence base.

The trauma awareness training is offered to all staff including clinical, managers, administration and reception staff. The training is a continuous rolling programme that new and existing staff can access, with refresher training offered three times a year. Requests for bespoke training for individual teams can be accessed as and when needed, by contacting the trauma informed care lead for CAMHS.

The start of a young person’s journey with the Trust is designed to be trauma informed. Clinicians will ask the appropriate person about adverse childhood experiences and trauma to take this into consideration with regards to signposting and further assessment.

Trauma-focused Therapeutic Interventions

When a young person has identified considerable adverse childhood experiences and trauma-related symptoms, they can access the complex developmental trauma pathway, post-traumatic stress disorder (PTSD) pathway, co-occurring difficulties, or Disorders of Severe Impact.

Each of the CAMHS pathways have been designed to be autism and trauma aware. This includes formulating and re-formulating points at which possible alternative underlying causes such as trauma are considered, especially if progress is not being made as would be expected. This includes trauma, which is fully or partially disclosed, or that which may be present but undisclosed. The pathways also take into consideration the young person and their family’s needs, and how the impact of trauma may affect their ability to access support as well as previous solutions they may have adopted to feel safe in past dangerous environments.

We have developed a trauma stabilisation pack with material from the trauma informed care programme and guidance for staff who are not trained in trauma-focused treatments to enable them to safely work with children and young people. This pack is accessed when someone is identified as experiencing post-trauma symptoms and helps them to understand what is happening to them. This is a very useful intervention to help prepare and stabilise people before they start the trauma-focused (TF) therapy. This is currently being evaluated and informal feedback is positive.

Ensuring that there is provision of trauma-focused psychological therapies is a second area of focus for workforce development. This is a specialist area of therapy and requires staff to be trained at a secondary level. We continue to train and support staff to deliver trauma-focused interventions through provision of expert clinical supervision and continuous professional development (CPD) opportunities. We are also aware of the need to continue to train staff to develop the skills to work with complex trauma presentations, and to provide the supervision and CPD required to sustain skills. We are not yet able to offer the level of provision that we would like and continue to focus on this aspect of workforce development.

As the needs of the young person increase, staff can access specialist services to support their work. Specialist services including Forensic CAMHS, intensive home treatment services, intensive positive behaviour support services and crisis services who use trauma informed approaches and are available throughout the Trust.

Our trauma informed approaches are cocreated with survivors of trauma, working alongside our peer support workers and cocreation leads, as well as the Trust’s lived experience directors, including our involvement members who are services users and carers. This has proved invaluable in improving and developing these approaches.

Recommendation 9

Health and social care agencies must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high.

TEWV response:

As providers of community care for children and young people we would work with our partners and the young person to ensure there is a safe discharge. Where known to the Trust, our community clinicians would remain involved with a young person throughout their inpatient stay in another hospital and attend discharge planning meetings. We are therefore aware of the importance of multi-agency and multi-disciplinary working, and to appropriately and robustly challenge where our staff are concerned about patient safety.

Where a professional agreement could not be reached and the Trust had concerns about unsafe discharge arrangements, then we would escalate this through our operational and safeguarding processes. We fully endorse this approach and can provide recent examples where this has been actioned.

Recommendation 10

Local Authorities and Health providers must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision where they are in the care of the Local Authority to ensure that support is holistic and meets the educational; social; physical health and emotional needs of children and young people as well as their mental health needs.

* We have provided some detail on actions we are taking to address these important issues, working alongside colleagues in the local authorities and health care providers.

TEWV response:

The Trust and all the local authorities across our geographical area have signed up to implementing iTHRIVE (detailed in the overarching context section), meaning that progress is being made with all our partners, and describes a whole-system approach. This is an important and positive change to our approaches to joint working with targeted support.

We are also working closely with our partner agencies to improve how we work together to support children, young people and their families. In Durham, we have been developing multi-agency decision making following a whole-system pathway development. This work has been led by the Trust over the past three years. Family hubs are also being developed in Consett, County Durham, Billingham, Stockton-on-Tees and in North Yorkshire and York. Included in the whole-system approach, we have also been developing an integrated multi-agency approach for high risk, vulnerable young people with joint accountability. Using this approach, risk assessment and management plans, safety plans are cocreated- between agencies and young people, their families and carers. Support comes from all sectors including family, social, activity, education and employment to enable the children and young people to settle back into their life in the community. Intensive home treatment (IHT) teams provide planned support which is tailored and bespoke for each individual, and this support is available in the Durham and Tees areas. There are also dedicated 24/7 CAMHS crisis teams across the Trust. The IHT and crisis teams work together with the multi-agency network, including CAMHS, to support children and young people when they leave inpatient accommodation.

TEWV have an active working group for 16-25’s, which led by an Associate Director of Therapies supported by a project manager. The working group oversees the transition process for CAMHS, AMHS and learning disability services. Transition panels are in place for each AMHS team. Active planning for the transition starts at six months prior to the young person’s 18^th birthday, with a discussion with the young person and their parent / carers which is recorded in the transition plan on electronic care records. Monthly reports are provided by team managers which are overseen by modern matrons, to check this happens. The last transition audit was completed in April 2020. An audit of transition planning formulations for complex presentations is planned for the next audit cycle.

For young people who are more vulnerable, we start to make links with adult mental health when a young person is 17 years and a quarter, with transition plans in place at 17 years and six months. We know that this transition time can be particularly difficult, especially for people in the care of the local authority, so we make sure that this is proactively done through preparation and follow-up actions. Multi-agency working across the transition time can be complicated, and it is recognised that young people often require additional support because of this. Our policies and procedures are based on previous CQUIN standards set by NHS England.

Recommendation 12

TEWV and CNTW must ensure the organisational approach to safeguarding young people proactively involves and informs the relevant local Safeguarding Children’s Partnership of all instances where a young person is placed at risk, including the use of unregulated and unsupported accommodation in the community.

As providers of community care for children and young people we would work with our partners and the young person to ensure there is a safe discharge. Where known to the Trust, our community clinicians would remain involved with a young person throughout their inpatient stay in another hospital and attend discharge planning meetings. Our responsibility is to work with local authority colleagues who are responsible for the safe transfer of individuals to appropriate accommodation. Where this cannot be met for any reason, the Trust will provide challenge and would escalate this through our operational and safeguarding processes.

Health and social care agencies must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high.

We fully endorse this approach and can provide recent examples where this has been actioned.

Recommendation 13

TEWV must ensure that services consider and document robust risk management processes to safeguard children where threats have been made to harm them by older family members who are also service users.

TEWV response:

The thorough risk assessment and management processes which consider harm to self and others, within the context of the persons family life, includes consideration of risk to younger siblings. Swift action is taken to address any threats to harm a child by others, which would be reported and referred to the appropriate local authority. Consultation with Forensic CAMHS is available for additional support and guidance. These processes are supported by the safeguarding lead within each CAMHS team.

Recommendation 17

TEWV should ensure there is much greater detail and understanding of the patterns and instances of harm within services through the regular reporting and interrogation of data, when required, to inform both individual patient clinical care planning, and Trust and service understanding of safety and quality issues.

TEWV response:

The Trust recognises the importance of using clinical incident data to inform patient care and to improve quality and safety. From the learning that has been gained, a series of training sessions have been provided to operational staff around how they can better use the Trust’s integrated information centre (IIC), which provides a range of information and reports on the quality and safety of care. This training covers how to use IIC effectively to understand the patterns and instances of harm at an individual and service level, and this analysis helps staff to identify any themes and trends. This information is used to inform individual plans of care, as well as enabling us to take improvement actions across services.

To make sure that there is greater ownership and oversight of individual patient safety incidents by each service, the Trust is placing the responsibility of incident management back to operational services. This will ensure that they are able to get greater detail and understanding of the patterns and incidence of harm in their clinical teams and use them for learning and safety purposes. Over 90% of our wards are actively using this, and we are continuing to support the embedding of this practice.

Whilst the Trust is in a period of transition from a centralised process to one of ownership and oversight by operational services, the central approval team continues to monitor repeated attempts of harm within our services.

A daily patient safety huddle takes place to review any new incidents where safety and quality may have impacted on patient care. Clinical services are requested to attend in order that a deeper understanding of the circumstances and any immediate learning can be actioned. There are a range of ways in which we use our information to identify patterns of harm and inform learning across our services. Information on incidents and complaints are shared at a weekly care group patient safety meeting, to identify any areas of immediate concern and enable timely actions to be taken. Through our governance systems we have a range of reports that measure key aspects of patient care, for example restrictive intervention, patient experience and patient safety incidents. Since 2019, we have introduced the use of statistical charts, and through these, we are able to better identify any areas of concern.

Recommendations 18 & 21 -have been combined – responses are outlined below and should be considered together.

Recommendation 18 & 21

Recommendation 18 – TEWV must redesign its response to incidents and patient safety to provide robust clinical governance, so that it conforms with the NHS England Serious Incident framework (SiF), its successor policies and other relevant guidance and best practice, so that it is assured that all relevant incidents are investigated thoroughly, and organisational learning can be quickly put in place.

Recommendation 21 – TEWV should review the Duty of Candour Policy and ensure that it is monitored through the relevant Board subcommittee processes. As part of this it must ensure that where there has been a death in a service, whether through self-harm/suicide or homicide, that families are given appropriate and regular family liaison and support through personal contact with a nominated officer of the Trust.  

TEWV response:

The Trust’s Serious Incident Framework (SIF) have been updated, and significant improvement work has been undertaken to strengthen its serious incident processes since 2019. This has included quality improvement and a ‘deep dive’ event involving feedback from service users, families and carers. Following the Trust’s final serious incident review panel,learning is distributed Trust-wide via a learning bulletin. If there are any urgent patient safety issues arising as part of the rapid review process, and to make sure there is swift action and early learning, these will be disseminated via a Trust-wide patient safety briefing. All staff can access these briefings via the patient safety learning library on the staff intranet. Any assurance obtained from associated actions is stored in the learning database.

We have undertaken an in-depth review of key themes from incidents dating back several years. This has enabled us to make measurable improvements and identify areas where further work is needed to embed learning. We are using our quality assurance schedule to inform this, to help develop and transform our organisational response to incidents, and the Trust is working towards the implementation of the new national patient safety incident response framework (PSIRF) by September 2023.

To build on this work, the Director of Quality Governance commissioned a quality improvement event called ‘Improving the experience of patients, families, and staff during serious incident reviews (SIRs)’. The event took place in July 2021, and the aim was to share with internal and external stakeholders the work that had been undertaken in the patient safety team in collaboration with families, patients and operational services, to:

• Improve the quality and safety of the care we provide.
• Improve the experience of patients and families throughout the serious incident review process.
• Improve the efficacy of our patient safety incident investigations by moving towards a systems-based approach identifying interconnected causal factors and systems.
• Address causal factors to prevent or minimise repeat patient safety risks and incidents.
• Measure the impact of actions taken to reduce repeat patient safety risks and incidents.
• To increase stakeholders (notably patients, families, carers, and staff) confidence in the improvement of patient safety through demonstrating the impact of learning from incidents.

A project manager was appointed to drive the continued delivery of this improvement work.

A further event was held in February 2022 with the NHS England support team and the patient safety team, where four additional work streams relating to the serious incident process and incident reporting were identified, including:

• The incident report process.
• Triaging patient safety incidents.
• Revisiting the duty of candour.
• The Trust’s final assurance panel for signing off serious incident reports.

On 20 May 2022, following completion of these workstreams with the relevant stakeholders, and in line with our improvement plan in Our Journey to Change, a further event called ‘Co-creating for Patient Safety’ took place. The event was attended by 70 people including bereaved families, carers, clinical services, members of the executive management team and commissioners. It focused on sharing details of the improvement work and facilitated full engagement with all relevant stakeholders.

The Incident Reporting and Serious Incident Review policy is being reviewed and updated to incorporate all outcomes of the improvement work.

All our current serious incident reviewers have received specialised training in serious incident investigation via the PSIRF approved trainers or the healthcare safety investigation branch (HSIB).

We have modified our rapid review response template, which is used for incidents categorised as near miss, moderate and above, to incorporate a section on duty of candour. This places the initial responsibility on clinical services to contact the patient or relevant other to apologise for the harm caused and to share information known at the time.

We recognise that staff in clinical services would benefit from some training in holding difficult conversations as well as the duty of candour, which has been captured in the Trust’s training needs analysis. The policy will be reviewed and revised to incorporate service improvements.

In addition, we will be commencing a review of our duty of candour processes in January 2023.

Recommendation 20

TEWV should ensure that it improves its response to complaints, so that complaints are managed in line with NHS England best practice guidance – tracking and reporting this through the relevant Board subcommittee processes.

TEWV response:

The Trust is working to improve its complaints process in line with NHS England best practice and guidance.

This includes introducing a more empathic approach into daily practice and improve culture and better outcomes for our patients, carers and their families. An ongoing programme of externally delivered empathy training in dealing with complaints and incidents has been undertaken since 2019. The Trust’s patient advice and liaison services (PALS) have also attended this training and have made changes in line with this.

A monthly report tracking complaint response times is reported through to the Trust’s Board Quality and Assurance Committee, Executive Quality Improvement Sub-Group, as well as the Trust’s two care group Quality Improvement Sub-Groups.

The Trust is due to start a full end-to-end review of the PALS and complaints’ function in November 2022, which is being led by the Trust’s lived experience directors, which is scheduled to complete in January 2023. This will explore a more restorative approach to PALS and complaint resolution. The review will involve services users, families and carers, Trust services as well as partners including those in the voluntary and community sector to cocreate and shape what these services look like in the future.