On this page
The reportDownload independent investigation report – Nadia Sharif
We understand that reading these reports may cause you to feel worried, upset or angry.
It’s important if you are in a mental health crisis that you get help. You can call our crisis line 24 hours a day. Find out more on what to do in a mental health crisis.
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 firstname.lastname@example.org. 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 Nadia SharifDownload TEWV response to the independent investigation – Nadia Sharif
Tees, Esk and Wear Valleys NHS Foundation Trust response to the recommendations in the Niche Health and Social Care Consulting independent investigation (NS)
The following assurance statements have been produced as a response to the Niche independent investigation into the care and treatment of NS in West Lane Hospital by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), commissioned by NHS England.
The independent investigation made a total of 12 recommendations.
This section addresses recommendations 1, 2, 3, 6, 7, 8 and 11 in order as made in the report.
Recommendations 4, 5,10 and 12 relate to other organisations and are therefore not included in this assurance statement. Recommendation 9 is a joint recommendation for TEWV, NHS England and Middlesborough Council. This statement provides only the TEWV response.
We would like to apologise unreservedly for the unacceptable failings in the care of Nadia 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 by 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 recruited two lived experience directors into our leadership team to make sure 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.
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. We 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, with 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 based on feedback from young people parents, carers and clinicians.
TEWV must ensure that plans of care for young people in Child and Adolescent Mental Health Services (CAMHS) incorporate evidence-based practice.
The Trust’s 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.
Considerable 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 recognises this is a work in progress and is subject to 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.
TEWV must ensure that risk assessments for young people in CAMHS are based on a psychological formulation and are developed by a multidisciplinary team in conjunction with the young person and their family.
In addition to the information provide above, 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 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 in place and 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.
TEWV must provide assurance that race and ethnicity, gender and religious issues are routinely addressed in Care Programme Approach (CPA) needs assessment and care planning as per the Trust’s policy.
The Trust addresses race, ethnicity, gender and religious issues in Care Programme Approaches in the following ways:
- To reduce any language barriers and ensure patients and families have access to information in a language they understand, the Trust uses a contracted interpretation and translation service called Everyday Language Solutions (ELS). This information is available on the staff intranet and is supported by an interpretation and translation policy. This service can be accessed by clinical staff to support patients and family members.
- To ensure there was better uptake of the offer from ELS, in 2022, we asked ELS to deliver Working with Interpreters training for our staff. The aim of the session was to give clinical staff more knowledge and a better understanding of how to use the interpretation service and how to work with interpreters.
In addition, the Trust’s Equality, Diversity and Human Rights (EDHR) team reviews all interpretation and translation usage. They contact teams directly to make sure colleagues are aware of the service, the policy that supports it and best practice including how often people should be offered it.
Since 2019, the use of ELS translation service has nearly doubled from seven to 13 a month, and the use of the interpreter service has gone from 182 to 265 requests per month.
- The Trust assesses and develops all policies, procedures and service changes to ensure that people from protected characteristic groups are not negatively impacted and that our services are inclusive.
- The Trust’s training offer has increased to make sure colleagues understand race and ethnicity, gender and religious issues and can take action to address them. This includes:
- Mandatory EDHR training for all staff.
- Equality and Diversity training.
- Human rights training – the EDHR team recently ran a human rights training programme for senior staff to embed human rights models into decision making. This helps clinicians to ensure care is person-centred.
- The EDHR team has developed and now delivers Compassion, Respect, Responsibility and Race training, to increase staff’s awareness of the experiences of people from a BAME (black, Asian and minority ethnic) background.
- The Trust also holds human rights supervisions, where staff can work through real life scenarios using human rights models and share good practice, including reverse mentoring.
TEWV must provide assurance that there are protocols in place for safeguarding and Local Authority Designated Officer (LADO) referrals, and that these are understood and followed by all staff caring for young people.
The Trust’s Safeguarding Children Policy was last updated in July 2022 and is available to all staff on the Trust intranet. This policy and related training reflect the protocols to be followed in relation to Local Authority Designated Officer (LADO) notification, where the member of staff works with children and an allegation is made.
To ensure that the correct procedures are followed, the Safeguarding Public Protection and Human Resources teams must be informed alongside the local authority. This means that the referral process has been considerably strengthened since 2019, and all referrals are checked by the safeguarding team before submission, to make sure that they contain all the relevant information needed.
The Trust’s safeguarding team is fully aware of the LADO procedures and ensure that allegations are escalated to the senior nominated officer in accordance with policy. To support staff to fulfil their safeguarding responsibilities, training for registered staff is refreshed every three years to ensure it meets both their practice and what’s required. It incorporates both adult and children safeguarding and is delivered via a mixture of e-learning, a workbook and virtual meetings. Additional bespoke training is provided as required. Safeguarding training compliance for CAMHS Clinicians is currently 88% and safeguarding leads in each CAMHS team provide support and supervision to front line staff. This is monitored via staff appraisals and safeguarding audit to ensure implementation of policies.
Recommendation 7 *
Where a young person is in receipt of T4 care and transferring back to T3, there must be a joint response between health and Middlesbrough Council children’s services so that the young person is prepared for life in the community and can be properly supported and their risks appropriately managed.
* We have provided some detail on actions we are taking to address this important issue, working alongside colleagues in the local authorities and health care providers. T3 or Tier 3 relates to community CAMHS services, and T4 of Tier 4 relates to inpatient CAMHS services.
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. We continue to work on multi-agency and multidisciplinary models of care within the Middlesbrough area. 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 co-created- 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, Adult Mental Health Services (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 18th birthday, with a discussion with the young person and their parent / carers which is recorded in the transition plan on electronic care records. A monthly report for team managers, overseen by modern matrons, provides assurance. 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 AMHS 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.
TEWV must provide assurance that clinical records are kept to expected standards.
In June 2021, the Trust introduced a new quality assurance programme focusing on the quality of clinical record keeping in relation to key clinical records including care plans, observation records, risk assessment and management plans recognising that high quality documentation is an enabler to good patient care. This is in line with national clinical record keeping policy and professional guidance for record keeping.
These audits are completed monthly and are verified through a peer review process. Results from Jun-21 to Jun-22 activities demonstrate consistent practice standards are being achieved across the organisation in terms of implementation of the minimum standards, in line with the Good Practice Guidance for the safety summary / safety plans, observation and engagement plans, and leave documentation within the patient electronic care record system. The Practice Development Practitioners continue to monitor compliance and to facilitate areas where focussed improvement work is required in collaboration with clinical teams.
In addition, clinical risk assessment and management guidance is provided to clinical staff to support their practice in line with the Trust’s revised Harm Minimisation policy (clinical risk assessment and management). Multi-disciplinary team (MDT) huddles were introduced in inpatient areas and outcomes are now recorded in clinical records. The quality assurance (QA) programme that was introduced in June 2021 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 observation recording forms being fully completed, specifying the named member of staff responsible for carrying out observation and engagement for each specified time-period.
TEWV/NHS England and Middlesbrough Council must provide assurance that all inpatient care for young people with a diagnosis of autism have care provided that is in line with the NICE guidance on autism spectrum disorder in under 19s: support and management.
We do adhere to this national guidance. A Trust-wide Autism Project has been providing training to clinical and corporate staff across all specialties, including adult inpatient services. Health Education England have developed the core capabilities framework standards and our training is aligned with this. It includes consideration of the impact of autism and consequent reasonable adjustments that staff may need to make when caring for and supporting an autistic child, young person or adult. This includes sensory considerations, social and environmental considerations and communication needs ensuring that care is individual to the response and responsive to their needs.
We have undertaken environmental checklists (recommended in NICE guidance) and this programme is underway for all wards. This creates a baseline of understanding of the sensory environment which then enables personalisation when autistic people are present on the ward.
We have also provided training for the estates department to ensure they are aware of the needs of autistic people.
From September 2020, the autism project has also offered consultation and supervision for clinical staff working with an autistic child, young person or adult accessing TEWV services in the community and as an inpatient. Reasonable adjustment workshops have been delivered (co-facilitated) in all adult mental health community teams across the trust.
In July 2022, a two-day scoping event was held to map out a significant piece of work looking at the reasonable adjustments needed specifically within our adult mental health inpatient services. Following this event, a number of themes were identified including communication needs, sensory considerations, staff training needs, environment and cultural change. With the support of the Autism Project team, each TEWV inpatient site will have a steering group to ensure the changes that were identified during the event are delivered. This group will be made up of key members of the service as well as Experts by Experience and people we support in our services. They will develop an implementation plan for their site which will be supported and monitored by the Autism Project team with clear timeframes for actions and outcomes.
TEWV Serious Incident processes must meet the expectations of the Serious Incident Framework and Duty of Candour.
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.