Report evidence summary
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to share clinically important information across mental health and primary care services
Wider context from the report “4. Communication between the community mental health team and other stakeholders was poor, with important information that had been identified (that Barry was depressed and not compliant with his medication) not being shared with the GP , nor were the GP or psychiatric team aware that Barry was not receiving any community support .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide planned community support
Wider context from the report “2. Community support did not take place as planned , and the family were not even made aware that this was awaited and Barry was on the list. It was not clear what, if any, information Barry had received apart from a very brief letter of discharge that specifically did not mention the community support.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Tolerance of persistent appointment delays
Wider context from the report “3. The expectation of the Local Authority is that appointments should take place within 28 days, but the unit is significantly under-resourced and delays are common and appear to be tolerated, and have been for some time . Earlier, timely appointments could assist in identifying and intervening with relapsing patients. This opportunity was lost.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide accessible information about care roles and contact routes
Wider context from the report “5. Information was not made readily available for either Barry, or the family who were trying to support him, of who was involved in his care, the extent of their role and who to contact to discuss this further or in case of any deterioration or change in presentation . This made the task of the supportive sister considerably more onerous and difficult and introduced unnecessary further delays in obtaining support for Barry at a time when his mental health was deteriorating and he was in need of urgent review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Delays in offering psychiatric follow-up appointments
Wider context from the report “1. Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months ; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at that time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to communicate awaited community support to patients and families
Wider context from the report “2. Community support did not take place as planned, and the family were not even made aware that this was awaited and Barry was on the list . It was not clear what, if any, information Barry had received apart from a very brief letter of discharge that specifically did not mention the community support .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Insufficient resourcing of the psychiatric unit
Wider context from the report “3. The expectation of the Local Authority is that appointments should take place within 28 days, but the unit is significantly under-resourced and delays are common and appear to be tolerated, and have been for some time. Earlier, timely appointments could assist in identifying and intervening with relapsing patients. This opportunity was lost.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to respond to non-attendance with clinical risk consideration
Wider context from the report “1. Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at that time .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an Enablement Service providing practical support from referral while people await mental-health assessment.
Verbatim wording from the response “Adult Social Care is currently restructuring and establishing an Enablement Service to work alongside the Adult Mental Health Social Work Teams. This service is designed to be in place for 1 April 2016 and will offer adults with mental health problems practical support from the point of referral so that no one should have to wait for an assessment.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact people awaiting case allocation fortnightly to identify changes and enable reprioritisation where necessary.
Verbatim wording from the response “In accordance with new processes, from 1 January 2016, anyone awaiting allocation will be contacted fortnightly by phone to check whether anything has changed and if the case needs re-prioritising. Team Support Workers within each team will undertake this task and report back to the Team Leader, who can then reprioritise cases as required. This process has been implemented via email from the Head of Service to Team Leaders on 15 December 2015 and will be followed up by conversations in team meetings.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce written notifications for people waiting over 14 days for assessment, including contact details, support information and copies for identified carers.
Verbatim wording from the response “In order to ensure an individual, and any relevant persons, are aware of the process following a referral to Adult Social Care a new process has been developed which will be effective from 1 January 2016. The process shall be triggered where Adult Mental Health identifies that someone will need to wait more than 14 days for an assessment from the point the case is transferred to the team. Adult Mental Health Teams will write to them explaining that they have been referred for an assessment, that they will be seen as soon as possible but that they should contact the team if anything changes. Any appropriate leaflets about other support services available will be sent out at this point.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement next-working-day telephone and two-day written feedback from AMHP assessments to relevant GPs.
Verbatim wording from the response “It is noted that the AMHP’s report to the Coroner identifies that the psychiatrists and AMHP assessing Mr Thraves were aware that he was not compliant with his medication. It is acknowledged that it should be standard practice for information to be shared with relevant professionals, such as the GP. In order to ensure this takes place in practice the Head of Service has e-mailed all AMHPs on 15 December 2015 to remind them of the importance of feeding back to GPs following an assessment under the Mental Health Act, where the GP was not part of that assessment.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fill vacancies and improve staffing capacity to reduce assessment waiting times.
Verbatim wording from the response “Unfortunately at this time the team was under particular pressure due to long term sickness and vacancies, subsequently resulting in individuals waiting a long period of time for assessments. It is most unfortunate that this consequently impacted upon Mr Thraves and also other people awaiting assessment at that time. Fortunately, the staffing situation has now improved, vacancies are filled, and waiting times for assessment have reduced.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Adult Mental Health social workers to share relevant information with the full multidisciplinary team and carers.
Verbatim wording from the response “Social workers across Adult Mental Health have been reminded of the importance of feeding back to the whole multi-disciplinary team and to carers, not solely the Registered Medical Officer.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the new assessment-waiting process through staff emails and team-meeting discussions.
Verbatim wording from the response “In order to ensure all staff are aware and adopt this process an email was sent to the relevant teams, by the Head of Service on 15 December and Team Leaders will discuss this in team meetings so that all workers are aware of the process.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and approve a revised Discharge Policy with detailed electronic discharge-letter requirements.
Verbatim wording from the response “The LPT Discharge Policy is currently under review and the new policy is due to be approved in February 2016.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require relevant information for patients and families to be documented in assessments and care plans.
Verbatim wording from the response “The CMHTs have also been informed in writing that relevant information must be made available for patients and their families, where this is provided it must be documented and made part of each individual’s assessment and care planning.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review publicity for the opt-in text reminder service to encourage patient uptake.
Verbatim wording from the response “Specifically our new patients are now being contacted a week before their scheduled appointment to remind them of the appointment date and time. If a patient is unable to attend then the appointment can be offered to someone else. Patients who missed their last appointment are also telephoned to remind them to attend and these patients are also bought to the attention of the clinician so that an assessment can be made as to whether or not any further action is required. A text reminder facility is available to patients who opt into the service and the publicity for this is being reviewed to encourage take up.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require medical and nursing staff to notify GPs when patients miss outpatient appointments.
Verbatim wording from the response “We agree with the inquest findings that communication between the Community Mental Health Team (CMHT) and wider stakeholders was poor. We agree that LPT did fail to communicate the fact that Barry did not attend his outpatient appointment to his GP and the steps regarding open contacts taken to prevent this happening in the future have been detailed are outlined above.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a multidisciplinary team help-caseload model through a North West Leicestershire pathfinder project.
Verbatim wording from the response “LPT’s CMHTs are currently undergoing service redesign. An important part of this redesign is to remove internal barriers between our Outpatients Service and the wider CMHT. Included in this redesign work is a pathfinder project in the North West Leicestershire CCG to look at a multi-disciplinary team help caseload model with the aim to roll this out across all CMHTs by April next year. We anticipate that this work will help to address the concern about Barry’s sister’s queries being passed between different parts of the team including the Consultant Psychiatrist and the referral management service.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise Local Authority assessment delays with the Head of Service.
Verbatim wording from the response “This is a question to be answered by our colleagues from the Local Authority as this is regarding the Local Authority’s Intensive Support Team, not an LPT service. The LPT Service Manager for Community Mental Health has raised the issue of long waiting times for assessments by the Local Authority Intensive Support team with the Head of Service in the Local Authority (City).” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a record-keeping audit including compliance with revised discharge-policy standards.
Verbatim wording from the response “We have informed our entire medical and nursing staff, in writing dated 1 December 2015 that they MUST write to GPs informing them about patients who Do Not Attend at our outpatient clinics as stated in the LPT DNA policy. In addition we will carry out an audit of the DNA policy to check compliance against the standards in the policy during quarter 2 of 2016/17. The record keeping audit, being scheduled for January 2016 will also include the recording of compliance with the standards within the revised discharge policy as described under point 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publicize and distribute the developed Trust Carers’ Pack to provide carers with information about processes and services.
Verbatim wording from the response “assist service improvement. The first event in the programme is to be held in January 2016. Additionally a Trust Carers’ Pack has been developed as part of an established CQUIN (Commissioning for Quality and Innovation) to provide information to carers about processes and services. The availability of the same will be widely publicized by the ward, outpatient staff, and service user and carer organisations. Team managers will be asked to cascade to all staff once it is completed and ready for distribution. It is anticipated that this will be completed by March 2016.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind community mental health staff to follow the Did Not Attend policy for missed appointments.
Verbatim wording from the response “Actions taken/planned:” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct regular spot checks of compliance with the Did Not Attend policy.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact new patients and recent non-attenders with appointment reminders, and alert clinicians to missed appointments for risk assessment.
Verbatim wording from the response “Specifically our new patients are now being contacted a week before their scheduled appointment to remind them of the appointment date and time. If a patient is unable to attend then the appointment can be offered to someone else. Patients who missed their last appointment are also telephoned to remind them to attend and these patients are also bought to the attention of the clinician so that an assessment can be made as to whether or not any further action is required. A text reminder facility is available to patients who opt into the service and the publicity for this is being reviewed to encourage take up.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor open patient contacts weekly and refer them to medical staff for clinical decisions.
Verbatim wording from the response “Since the beginning of November 2015 what are known as ‘open contacts’ on the patient electronic record (RiO) are being monitored on a weekly basis. This is where a patient has had an appointment date that has passed but the episode of care has not been closed on the record, either by a record of the appointment having taken place or evidence of a further appointment offered. These will be drawn to the” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the Did Not Attend policy during quarter two of 2016/17.
Verbatim wording from the response “We have informed our entire medical and nursing staff, in writing dated 1 December 2015 that they MUST write to GPs informing them about patients who Do Not Attend at our outpatient clinics as stated in the LPT DNA policy. In addition we will carry out an audit of the DNA policy to check compliance against the standards in the policy during quarter 2 of 2016/17. The record keeping audit, being scheduled for January 2016 will also include the recording of compliance with the standards within the revised discharge policy as described under point 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase outpatient appointment capacity through a programme maximizing use of clinical appointment slots.
Verbatim wording from the response “In the period between completion of the investigation and leading up to the Coroner’s inquest LPT has been undertaking a programme of specific work to ensure that the maximum use of clinical appointment slots are available in the Adult Mental Health Outpatients department thereby increasing the availability of appointments to our patients. This will reduce the numbers of people who are not attending appointments.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redesign community mental health services to remove internal barriers between outpatient and wider community teams.
Verbatim wording from the response “LPT’s CMHTs are currently undergoing service redesign. An important part of this redesign is to remove internal barriers between our Outpatients Service and the wider CMHT. Included in this redesign work is a pathfinder project in the North West Leicestershire CCG to look at a multi-disciplinary team help caseload model with the aim to roll this out across all CMHTs by April next year. We anticipate that this work will help to address the concern about Barry’s sister’s queries being passed between different parts of the team including the Consultant Psychiatrist and the referral management service.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate an interim missed-appointment flow chart to community mental health teams.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the response’s actions through service clinical-governance arrangements.
Verbatim wording from the response “All of the actions outlined in this response will be monitored through the service’s clinical governance arrangements.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Did Not Attend policy and introduce a flow chart for responding to missed appointments.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to include referrals to other agencies in discharge letters and communicate them clearly to patients and carers.
Verbatim wording from the response “Actions taken/planned:” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a partial-booking system for outpatient appointments.
Verbatim wording from the response “LPT is also working towards a ‘partial booking’ system for outpatient appointments whereby appointments are booked much closer to the scheduled date to be seen allowing for a more flexible use of available appointments and a reduction in cancelled clinics. Cancelling of clinics is sometimes unavoidable but it is subject to Clinical Director approval and an action plan to monitor compliance and improvement is scrutinized for assurance at the LPT Quality Assurance Committee.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to obtain and document family members’ views during assessments and include them in assessment outcomes.
Verbatim wording from the response “In addition staff have been reminded that where family members are present during an assessment they must be offered the opportunity to give their views, observations and understanding in relation to the crisis and the support they may be able to provide. This information will be documented on the assessment form by the assessing professional and form part of the outcome of assessment. This has been communicated in writing to our CMHTs.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a Listening into Action programme on involving patients and carers in care planning.
Verbatim wording from the response “Actions taken/planned:” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern about psychiatric follow-up falls to Leicestershire Partnership Trust, which will respond separately.
Verbatim wording from the response “This concern relates to Leicestershire Partnership Trust’s involvement with Mr Thraves and I am aware that the Trust will be responding to you on this point.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority’s Intensive Support Team is not an LPT service, so the matter falls outside LPT’s remit.
Verbatim wording from the response “This is a question to be answered by our colleagues from the Local Authority as this is regarding the Local Authority’s Intensive Support Team, not an LPT service. The LPT Service Manager for Community Mental Health has raised the issue of long waiting times for assessments by the Local Authority Intensive Support team with the Head of Service in the Local Authority (City).” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority is responsible for answering concerns about delays in its Intensive Support Team’s assessments.
Verbatim wording from the response “This is a question to be answered by our colleagues from the Local Authority as this is regarding the Local Authority’s Intensive Support Team, not an LPT service. The LPT Service Manager for Community Mental Health has raised the issue of long waiting times for assessments by the Local Authority Intensive Support team with the Head of Service in the Local Authority (City).” Source location 2015-0443-Response2
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