Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 27
Action
Provide bespoke Mental Capacity Act training to designated staff cohorts.
Stated by Bolton NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source
Action
Provide a single hospital-based care coordinator for each patient and record coordination input in electronic and social services records.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Provide assessment wards and the Emergency Department with a full Integrated Discharge Team service and assign a lead care coordinator for each patient's discharge planning.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Introduce a single electronic patient record for recording and sharing patient details, notes and actions.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Make Mental Capacity Act forms available for completion by all staff designations on the Electronic Patient Record.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Review and revise Mental Capacity Act training provision to clarify roles and responsibilities for relevant clinical staff.
Stated by Bolton NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source
Action
Develop a competency framework for identifying and assessing patients with complex health, social and onward care needs.
Stated by Bolton NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source
Action
Strengthen and ratify the Mental Capacity Act policy to clarify assessment responsibilities, decision makers and Independent Mental Capacity Advocate referrals.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Require ward managers to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before transfer of care.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Bring the Home First Team, inpatient therapy services and Integrated Discharge Team under a single management structure.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Develop a Home First competency framework for recommending appropriate intermediate-care placements.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Review transfers to intermediate care daily through an Integrated Discharge Team nurse.
Stated by Bolton NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source
Action
Review the Patient Outlier Policy with stakeholders to clarify guidance for minimising risks to patients cared for outside their specialty wards.
Stated by Bolton NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source
Action
Share inquest learning with senior management and leadership teams and put an action plan in place to keep staff current with Best Interest, Capacity and CPA training.
Stated by Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Stated by Greater Manchester Mental Health NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source
Action
Advise care coordinators to proactively contact acute trusts and coordinate care when service users move between wards, hospitals or care settings.
Stated by Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Stated by Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Use the care coordinator as the single mental health contact for hospital admissions and require re-entry into hospital care to maintain communication and consistency.
Stated by Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Require wards to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before considering transfer of care.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Record Integrated Discharge Team input in patients’ electronic patient records and social services case-recording systems.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 9 June 2020. View source
Action
Develop a skills and competency framework for Integrated Discharge Team members to identify patients with complex onward needs.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source
Action
Deliver additional training to existing Integrated Discharge Team staff on identifying patients with complex onward needs.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source
Action
Bring the Home First Team, inpatient therapy services and Integrated Discharge Team under a single management structure to improve communication.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Establish a single care-coordinator point of contact, with care coordinators providing hospital in-reach for involved service users.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Share the report’s concerns with NHS England and NHS Improvement to inform work on coordinated community mental health services.
Stated by Department of Health and Social Care Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
Action
Contact Bolton’s Principal Social Worker and the Greater Manchester Mental Health NHS Foundation Trust’s Director of Nursing and Governance to discuss progress on integrated care changes and protocols.
Stated by Department of Health and Social Care Stated plannedThe respondent said that this action was planned when they made their response on 9 June 2020. View source See 24 more actions
× 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 Placement without a clear understanding of the person's needs
Wider context from the report “7. His placement at Laburnum Lodge was made without a clear understanding of his needs . He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.
” 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 suitable ward placement due to capacity and flow constraints
Wider context from the report “2. The inquest heard that he was kept on wards that were not suitable for him or his needs . The inquest was told that this was due to capacity and flow issues within the Royal Bolton Hospital.
” 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 supervise eating when supervision is required
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised , he dropped it on himself and suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort.
” 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 Lack of interagency understanding of roles and responsibilities
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place. There was a lack of understanding between agencies of roles and responsibilities under the integrated care model .
” 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 of care coordinators to lead support and best-interests processes in acute settings
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place . There was a lack of understanding between agencies of roles and responsibilities under the integrated care model.
” 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 Unclear responsibility for care decisions and placement suitability assessment
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement .
” 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 ensure food is served at a safe temperature
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn . The burn did not contribute to his death but did cause significant additional discomfort.
” 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 Poor-quality care documentation
Wider context from the report “1. The quality of the documentation was not always of a good standard and part of the reason why his catheter was incorrectly believed to be a long term catheter.
” 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 Lack of coordination and ownership of care in acute settings
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care . It was unclear as to who was making decisions and assessing suitability of placement.
” 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 recognise lack of decision-making capacity
Wider context from the report “5. The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care . Acquiescence by him was seen as him understanding and having capacity .
” Open source report
×
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 Provide bespoke Mental Capacity Act training to designated staff cohorts.
Verbatim wording from the response “• There has been a review of training provision in respect of the Mental Capacity Act (MCA). Bespoke training is now provided to designated cohorts and will be completed by 30th September 2020.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 Provide a single hospital-based care coordinator for each patient and record coordination input in electronic and social services records.
Verbatim wording from the response “The IDT has identified that the role of a seconded mental health post within the team was a key omission in the management of Mr Preston’s journey. The use of different organisation’s case recording systems also resulted in the failure to identify that the patient already had a care coordinator in the community and the needs to identify an IMCA to represent the patient’s best interest. Since this incident the IDT has in conjunction with GMMHFT, removed this role from the service in order to provide a single care coordinator (this will either be a social worker or discharge nurse) for each patient who is hospital based and will liaise with other organisations where needed. All input will be recorded in the patient’s electronic patient record and social services case recording systems.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 Provide assessment wards and the Emergency Department with a full Integrated Discharge Team service and assign a lead care coordinator for each patient's discharge planning.
Verbatim wording from the response “At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in-reach model which was reliant on other professionals to identify those patients who had existing social care needs prior to admission to hospital. The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards, as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 a single electronic patient record for recording and sharing patient details, notes and actions.
Verbatim wording from the response “Since the death of Mr Preston, Bolton NHS Foundation Trust has introduced an Electronic Patient Record (EPR). This is the single electronic record on which all patient details, notes and actions are recorded.
All staff within Royal Bolton Hospital have access to view and record patient details on the system. The Integrated Discharge Team and the Intermediate Tier Services can also view and input into the electronic patient record which has improved the standard and consistency of documentation in real time.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 Make Mental Capacity Act forms available for completion by all staff designations on the Electronic Patient Record.
Verbatim wording from the response “• MCA forms are now available for completion by all designations of staff on the Electronic Patient Record.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 revise Mental Capacity Act training provision to clarify roles and responsibilities for relevant clinical staff.
Verbatim wording from the response “In conjunction with the review, Bolton NHS Foundation Trust is revising mandatory and non-mandatory training provision in respect of the Mental Capacity Act which Medical Staff, Nurses and Allied Health Care Professionals undertake, ensuring clarification of roles and responsibilities.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 competency framework for identifying and assessing patients with complex health, social and onward care needs.
Verbatim wording from the response “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 Strengthen and ratify the Mental Capacity Act policy to clarify assessment responsibilities, decision makers and Independent Mental Capacity Advocate referrals.
Verbatim wording from the response “In response to the concern raised of poor appreciation of the gentleman’s lack of capacity to make decisions about his care, BFT has completed a review of the ‘Mental Capacity Act 2005’ policy. The narrative in the policy has been strengthened in respect of defining roles and responsibilities in the application of mental capacity assessments and there is clarity as to whom should be ‘The Decision Maker’ and the legal requirement for referral and involvement of Independent Mental Capacity Advocates in the absence of a relevant representative. The revised policy has been ratified by the Safeguarding Committee on 16th June 2020.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 ward managers to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before transfer of care.
Verbatim wording from the response “• Ward Managers have been instructed that any patient with complex needs should be escalated to the IDT for a full MDT meeting where any transfer of care is being considered.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 Bring the Home First Team, inpatient therapy services and Integrated Discharge Team under a single management structure.
Verbatim wording from the response “During the period of time that Mr Preston was an inpatient he was seen by multiple teams including the Home First Team, inpatient therapy services and the Integrated Discharge Team (IDT). Since this incident it has been recognised that there were multiple handovers between teams and these teams have now been brought together under a single management structure in order to provide improved communication between staff groups and lead to better patient experience.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 Home First competency framework for recommending appropriate intermediate-care placements.
Verbatim wording from the response “The Home First team are a therapy based team which aims to support those patients in the ED and assessment wards to return home without a longer period of hospital admission. It has been identified that there is a skills gap within this team and a competency framework has been developed to support staff in making the appropriate recommendation for placement at intermediate care units. In order to ensure all transfers are safe these will be reviewed on a daily basis by a member of the nursing team within the IDT.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 transfers to intermediate care daily through an Integrated Discharge Team nurse.
Verbatim wording from the response “The Home First team are a therapy based team which aims to support those patients in the ED and assessment wards to return home without a longer period of hospital admission. It has been identified that there is a skills gap within this team and a competency framework has been developed to support staff in making the appropriate recommendation for placement at intermediate care units. In order to ensure all transfers are safe these will be reviewed on a daily basis by a member of the nursing team within the IDT.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 Patient Outlier Policy with stakeholders to clarify guidance for minimising risks to patients cared for outside their specialty wards.
Verbatim wording from the response “Currently, a review of the Patient Outlier Policy is being undertaken to ensure there is clear guidance in order to minimise the risks associated with patients being cared for on all wards irrespective of the speciality nature of the ward. This review is being undertaken throughout June and July 2020, engaging relevant stakeholders and led by a senior manager in consultation with the Deputy Director of Operations, Director of Quality Governance and senior Nursing and Clinical staff. The new Patient Outlier Policy will be rolled out across the Trust on 1st August 2020 provided the current COVID-19 pandemic circumstances do not delay its introduction.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
×
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 Share inquest learning with senior management and leadership teams and put an action plan in place to keep staff current with Best Interest, Capacity and CPA training.
Verbatim wording from the response “Learning form the inquest has been shared with the Senior Management Teams, over both Adult and Older Adult Services and with the Senior Leadership Teams, which has an overarching responsibility within Bolton Mental Health Services and an action plan put in place to ensure that all staff are up to date with Best Interest & Capacity Training and Care Programme Approach (CPA) training, which is monitored by team managers. Learning from the inquest will be shared trust wide, via the trust wide Care Programme Approach (CPA) meeting.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
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 Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Verbatim wording from the response “Through supervision and team meetings, all staff have been informed of the expectations of a care coordinator when patients are admitted to alternative care settings, such as acute trusts, and informed that they must consider support from advocacy / IMCA. Team Managers will proactively review cases where individuals have been admitted to other care settings in supervision to ensure that care coordinator are proactively coordinating the individuals care, and consideration has been given to Capacity and Best Interest meetings, where appropriate.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
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 Advise care coordinators to proactively contact acute trusts and coordinate care when service users move between wards, hospitals or care settings.
Verbatim wording from the response “• Care coordinators have been advised that as part of their role, they are expected to proactively in-reach into acute trusts, to ensure effective communication is facilitated, to mitigate risks of individuals being moved between wards / hospitals / other care settings without the care coordinator being informed; this will enable to care coordinator to appropriately coordinate care, taking into account an individual's holistic needs. (This is outlined with the Older Adult Service Operational Procedure and the Policy for the Transfer of Service Users to Acute Care).” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
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 Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Verbatim wording from the response “• Team Managers have discussed the expectations with all staff, that every time there is a significant change in an individual's circumstance, that capacity assessments & Best Interest Meetings are considered and clearly recorded, and that care coordinators ensure they proactively liaise with other care providers to ensure any changes to the care plan can be reviewed and updated appropriately, and this is being monitored via supervision.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
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 Use the care coordinator as the single mental health contact for hospital admissions and require re-entry into hospital care to maintain communication and consistency.
Verbatim wording from the response “A review of the mental health practitioner role within the Integrated Discharge Team had commenced prior to the death of Mr Preston, however following a subsequent review with the Local Authority and Bolton Foundation Trust, taking into consideration the concerns noted within the inquest, the decision has been taken to end the secondment of the mental health social worker and return the practitioner to their substantive post within Greater Manchester Mental Health. Going forward there is now one point of contact with mental health services, the care coordinator, who will on re-arch into the hospital when any service user they are involved with is admitted, to provide consistency and ensure hospital staff are aware of any input from mental health services.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
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 wards to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before considering transfer of care.
Verbatim wording from the response “Actions taken by Bolton Council and BNFT” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
Open published response
×
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 Record Integrated Discharge Team input in patients’ electronic patient records and social services case-recording systems.
Verbatim wording from the response “The IDT has identified that the role of a seconded mental health role within the team was a key omission in the management of Mr Preston’s Journey. The use of different organisation’s case recording systems also resulted in the failure to identify that the patient already had a care coordinator in the community and the needs to identify an IMCA to represent the patient’s best interest. Since this incident the IDT has in conjunction with GMMHFT, removed this role from the service in order to provide a single care coordinator (this will either be a social worker or discharge nurse) for each patient who is hospital based and will liaise with other organisations where needed. All input will be recorded in the patient’s electronic patient record and social services case recording systems.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
Open published response
×
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 skills and competency framework for Integrated Discharge Team members to identify patients with complex onward needs.
Verbatim wording from the response “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 Response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
Open published response
×
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 additional training to existing Integrated Discharge Team staff on identifying patients with complex onward needs.
Verbatim wording from the response “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 Response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
Open published response
×
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 Bring the Home First Team, inpatient therapy services and Integrated Discharge Team under a single management structure to improve communication.
Verbatim wording from the response “During the period of time that Mr Preston was an inpatient he was seen by multiple teams including the Home First Team, inpatient therapy services and the IDT. Since this incident it has been recognised that there were multiple handovers between teams and these teams have now been brought together under a single management structure in order to provide improved communication between staff groups and lead to better patient experience.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
Open published response
×
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 a single care-coordinator point of contact, with care coordinators providing hospital in-reach for involved service users.
Verbatim wording from the response “A review of the mental health practitioner role within the IDT had commenced prior to the death of Mr Preston, however following a subsequent review with the Local Authority and BNFT, taking into consideration the concerns noted within the inquest, the decision has been taken to end the secondment of the mental health social worker and return the postholder to Greater Manchester Mental Health. There is now one point of contact, which is the care coordinator, who will in-reach into the hospital when any service user they are involved with is admitted.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
Open published response
×
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 Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
Verbatim wording from the response “At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in-reach model which was reliant on other professionals identify those patients who had existing social care needs prior to admission to hospital. The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
Open published response
×
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 Share the report’s concerns with NHS England and NHS Improvement to inform work on coordinated community mental health services.
Verbatim wording from the response “Officials have shared the concerns in your report with NHSEI so that they can be considered as work to deliver improved, co-ordinated community mental health services progresses, in particular, guidance to mental health trusts on partnership working and use of the Care Programme Approach, especially when the person has mental and physical health issues.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
×
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 Bolton’s Principal Social Worker and the Greater Manchester Mental Health NHS Foundation Trust’s Director of Nursing and Governance to discuss progress on integrated care changes and protocols.
Verbatim wording from the response “In light of your report, the Chief Social Workers for Adults office will make contact with the Principal Social Worker for Bolton and the Director of Nursing and Governance at the Greater Manchester Mental Health NHS Foundation Trust to discuss the progress that both organisations have made in developing and implementing changes to their integrated care model and protocols for people with physical and mental health issues.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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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 GMMHFT will provide a further response concerning mental capacity assessment and advocacy arrangements.
Verbatim wording from the response “Section 5 (5): The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care. Acquiescence by him was seen as him understanding and having capacity.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 Bolton Council and GMMHFT will provide the full response to concerns about community care coordination and agency roles.
Verbatim wording from the response “Section 5 (3) The inquest heard that he had a care coordinator in the community. However, the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interest meetings were taking place. There was a lack of understanding between agencies of role and responsibilities under the integrated care model.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 will provide a further response on actions concerning safe placement and transfers of care.
Verbatim wording from the response “Section 5 (7): His placement at Laburnum Lodge was made without clear understanding of his needs. He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 Bolton Council will provide a further detailed response on aspects of care coordination, ownership and decision-making.
Verbatim wording from the response “I am advised that Bolton Council Local Authority will also be providing you with a detailed response to Section 5 (4).” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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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 Trafford Council was responsible for a safeguarding investigation if the hospital referred the burn incident under section 42.
Verbatim wording from the response “Whilst the Manchester Foundation Trust completed its own internal root cause analysis it is not clear whether they referred this incident to Trafford Council for a section 42 Safeguarding Investigation under the Care Act 2014. As the host authority, Trafford Council would have been responsible for undertaking the investigation had it been referred to them by the hospital but they would have notified Bolton Council if this was the case as Bolton was the authority where Mr Preston was ordinarily resident.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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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 Greater Manchester Mental Health Foundation Trust addresses care coordinator responsibilities.
Verbatim wording from the response “The point regarding care coordinator responsibilities is addressed in point (4) by GMMH. However, with regard to the lack of understanding of roles and responsibilities under the integrated care model, we have made some changes following the inquest which should provide assurance.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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 Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Verbatim wording from the response “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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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 Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Verbatim wording from the response “I expect the Bolton NHS Foundation Trust, the Greater Manchester Mental Health NHS Foundation Trust and Bolton Council to carefully consider and respond to the specific concerns highlighted by your report. I am advised that Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust have apologised for the lack of co-ordination in Mr Preston’s care while he was in hospital and the failure to conduct a formal assessment of Mr Preston’s mental capacity. You will know from the responses of the NHS trusts and Bolton Council to your report that they have worked together to resolve the matters of concern highlighted, with several actions taken to improve the co-ordination and quality of care for people with physical and mental health problems. I am pleased to see that learnings are being taken from the circumstances around Mr Preston’s care.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
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Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 5 1 Require a full multidisciplinary meeting before reducing enhanced care levels for patients.
Stated by Bolton NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source 2 Train Integrated Discharge Team staff to apply the competency framework and identify patients with complex needs.
Stated by Bolton NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020. View source 3 End the mental health social worker’s secondment to the Integrated Discharge Team and return the practitioner to their substantive post.
Stated by Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source 4 Share the inquest learning trust-wide through the Care Programme Approach meeting.
Stated by Greater Manchester Mental Health NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 9 June 2020. View source 5 Require ward staff to obtain a full multidisciplinary meeting before reducing a patient’s level of enhanced care.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 9 June 2020. View source
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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 a full multidisciplinary meeting before reducing enhanced care levels for patients.
Verbatim wording from the response “• All wards have been advised that the decision to reduce the level of enhanced care should not be undertaken by ward staff without a full multi-disciplinary meeting.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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 Train Integrated Discharge Team staff to apply the competency framework and identify patients with complex needs.
Verbatim wording from the response “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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 End the mental health social worker’s secondment to the Integrated Discharge Team and return the practitioner to their substantive post.
Verbatim wording from the response “A review of the mental health practitioner role within the Integrated Discharge Team had commenced prior to the death of Mr Preston, however following a subsequent review with the Local Authority and Bolton Foundation Trust, taking into consideration the concerns noted within the inquest, the decision has been taken to end the secondment of the mental health social worker and return the practitioner to their substantive post within Greater Manchester Mental Health. Going forward there is now one point of contact with mental health services, the care coordinator, who will on re-arch into the hospital when any service user they are involved with is admitted, to provide consistency and ensure hospital staff are aware of any input from mental health services.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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 Share the inquest learning trust-wide through the Care Programme Approach meeting.
Verbatim wording from the response “Learning form the inquest has been shared with the Senior Management Teams, over both Adult and Older Adult Services and with the Senior Leadership Teams, which has an overarching responsibility within Bolton Mental Health Services and an action plan put in place to ensure that all staff are up to date with Best Interest & Capacity Training and Care Programme Approach (CPA) training, which is monitored by team managers. Learning from the inquest will be shared trust wide, via the trust wide Care Programme Approach (CPA) meeting.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
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 ward staff to obtain a full multidisciplinary meeting before reducing a patient’s level of enhanced care.
Verbatim wording from the response “Actions taken by Bolton Council and BNFT” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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