Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 35
The Trust Conduct monthly QA5 audits of safety-summary and safety-plan quality, risk mitigation documentation, and completion, with corrective action and clinical supervision.
View source
The Trust Allocate safeguarding duty workers to provide immediate advice and support during core working hours.
View source
The Trust Arrange for crisis clinicians to attend Connecting with People suicide-awareness training.
View source
The Trust Embed the national triage tool through practitioner induction, staff education, and trained senior-practitioner completion of triages.
View source
The Trust Issue and disseminate a Patient Safety Briefing communicating safeguarding learning across the organisation.
View source
The Trust Implement monthly caseload-management supervision supported by an electronic caseload dashboard and review of essential care documents.
View source
The Trust Use an escalation procedure to obtain senior-management intervention and deploy staff or managers when crisis assessments risk breaching timescales.
View source
The Trust Allocate safeguarding-team links to clinical areas to provide safeguarding support and guidance.
View source
The Trust Deliver additional training on completing safety summaries and safety plans to crisis staff.
View source
The Trust Discuss safeguarding concerns daily in community and crisis huddles, assign actions, and share incident learning and review findings with teams.
View source
The Trust Check and discuss every patient’s safety summary and safety plan during daily Crisis Team huddles, assigning required updates.
View source
The Trust Audit triage-tool use and documentation monthly through QA5 and review compliance in clinical supervision and quality-assurance processes.
View source
The Trust Provide regular bespoke safety-summary and safety-plan training, including training for new team members.
View source
The Trust Provide additional training on the Parental Mental Ill Health and Children tool to support safeguarding-referral decisions.
View source
The Trust Enhance QA5 auditing to assess PAMIC completion, safeguarding identification, and completion of appropriate safeguarding actions.
View source
The Trust Review crisis-service staffing daily, attend safe-staffing meetings, and identify alternative resources during increased acuity.
View source
The Trust Monitor urgent-referral response compliance through weekly reporting, governance review, monthly specialty reporting, and Care Group escalation.
View source
Tees, Esk and Wear Valleys NHS FT Introduce an escalation procedure requiring delayed-assessment concerns to be discussed with senior management and resourced through redeployment or management clinical support.
View source
Tees, Esk and Wear Valleys NHS FT Implement monthly caseload-management supervision and an electronic caseload dashboard to identify supervision needs and review essential care documents.
View source
Tees, Esk and Wear Valleys NHS FT Provide additional training for crisis staff on completing safety summaries and safety plans.
View source
Tees, Esk and Wear Valleys NHS FT Make safeguarding concerns a daily community and crisis-huddle agenda item, assign resulting actions and share incident learning with teams.
View source
Tees, Esk and Wear Valleys NHS FT Induct current and new crisis-team practitioners in crisis processes, triage-tool use and the rationale for senior-practitioner triage.
View source
Tees, Esk and Wear Valleys NHS FT Issue and disseminate a Patient Safety Briefing on the incident’s safeguarding learning across the organisation.
View source
Tees, Esk and Wear Valleys NHS FT Expand QA5 audits to review PAMIC completion, safeguarding identification and completion of appropriate safeguarding actions.
View source
Tees, Esk and Wear Valleys NHS FT Allocate safeguarding duty workers to provide immediate advice and support during core working hours.
View source
Tees, Esk and Wear Valleys NHS FT Apply the national triage tool to new or otherwise eligible crisis-service patients and develop interim safety plans with patients and carers.
View source
Tees, Esk and Wear Valleys NHS FT Check and discuss every patient’s safety summary and safety plan during daily Crisis Team huddles, assigning staff to complete required updates.
View source
Tees, Esk and Wear Valleys NHS FT Conduct monthly QA5 audits of safety-summary and safety-plan quality, risk mitigation documentation and completion, with corrective action and clinical supervision where needed.
View source
Tees, Esk and Wear Valleys NHS FT Report and govern very-urgent referral response compliance through weekly monitoring, monthly specialty governance reporting and Care Group escalation.
View source
Tees, Esk and Wear Valleys NHS FT Arrange for crisis clinicians to attend Connecting with People suicide-awareness training.
View source
Tees, Esk and Wear Valleys NHS FT Deliver regular bespoke safety-summary and safety-plan training, including training during induction for new team staff.
View source
Tees, Esk and Wear Valleys NHS FT Audit crisis-team triage-tool completion and quality monthly through QA5 and reinforce compliance through clinician supervision.
View source
Tees, Esk and Wear Valleys NHS FT Review crisis-service staffing daily, attend safe-staffing meetings and arrange alternative staffing support when demand threatens timely assessments.
View source
Tees, Esk and Wear Valleys NHS FT Provide additional staff training on the PAMIC tool to support recognition and referral of safeguarding concerns affecting children.
View source
Tees, Esk and Wear Valleys NHS FT Assign safeguarding-team links to clinical areas to provide teams with additional safeguarding support and guidance.
View source
× 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 make safeguarding referrals for children in all warranted situations
Wider context from the report “3. In relation to making safeguarding referrals for children, the evidence I heard was in this particular case a referral should have been made and was not . I was told training had been undertaken to make all staff aware of what action to take. However, I was told in the majority of occasions it was believed a referral would be made. It is of concern in terms of protecting children that I was not satisfied that a referral was made in all situations that warranted such a referral.
” 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 complete Safety Plans in all cases
Wider context from the report “4. I was told in evidence that a Safety Plan which is complied with input from the patient, their families and practitioners did not exist in Mr STOUT's case. I was told it is crucial document for identifying risks and ways to mitigate them. I was also told work was commenced by your organisation in December 2020 to ensure full and complete compliance with this requirement, but I was not reassured there was such compliance with the completion of Safety Plans in all cases at this 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 complete the Triage Tool at every Crisis Team contact
Wider context from the report “2. The Triage Tool was explained in evidence to be essential in ensuring the patient received the correct treatment/service and is to be undertaken every time a patient contacts the Crisis Team. I was informed there was an aspiration to achieve a completion of the Triage Tool every time, but it is not being completed on every occasion . It is of concern that such a key document which identifies risk, care and other matters is not completed on every occasion as it is mandated to be done.
” 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 complete timely mental health crisis assessment within the set time period
Wider context from the report “1. The nationally set time from initial contact with the Crisis Team to some form of assessment is 4 hours. I heard evidence that achievement of this target in every case is not realised . It is of concern that timely assessment and treatment of person undergoing a mental health crisis should be assessed as speedily as possible and within the set time period .
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 Conduct monthly QA5 audits of safety-summary and safety-plan quality, risk mitigation documentation, and completion, with corrective action and clinical supervision.
Verbatim wording from the response “Within the Early Intervention in Psychosis (EIP) Team, staff have regular caseload supervision which looks at patient care and safety management documents such as the safety summary and safety plan. Results from QA5 audits are fed back to staff in monthly team meetings. Audit outcomes are reviewed through service and speciality governance meetings and escalated through to Care Group Boards. A function of these groups is also to develop and monitor improvement plans and actions for areas where audit compliance falls below the expected standard.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Allocate safeguarding duty workers to provide immediate advice and support during core working hours.
Verbatim wording from the response “Additionally, to provide immediate support and advice during core working hours, the Trust have allocated safeguarding duty workers. This professional lead is available to discuss any safeguarding concerns and to offer guidance on how to address concerns safely, ensuring a child’s welfare remains a central priority. Outside of regular working hours, the Trust safeguarding policy directs staff to contact the local authority safeguarding team to ensure that concerns are promptly discussed and addressed as required.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Arrange for crisis clinicians to attend Connecting with People suicide-awareness training.
Verbatim wording from the response “All staff complete the Trust mandatory Harm Minimisation training. This training supports clinicians to develop skills and competence in the completion of person-centred safety plans that look at a range of risk factors when safety planning. Additionally, the crisis service is arranging for crisis clinicians to attend the non-mandatory “Connecting with People” suicide awareness training.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Embed the national triage tool through practitioner induction, staff education, and trained senior-practitioner completion of triages.
Verbatim wording from the response “In evidence, HMC heard evidence from ████████ that development work had been undertaken in the Durham and Darlington area in relation to the triage tool assessment process and staff development.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Issue and disseminate a Patient Safety Briefing communicating safeguarding learning across the organisation.
Verbatim wording from the response “To strengthen safeguarding practices across the organisation, the Trust safeguarding team allocate members of the team to link in with different clinical areas across the Trust. This provides increased support and guidance within the teams, enabling timely and effective handling of safeguarding concerns. The organisation has also issued a Patient Safety Briefing following this incident, this briefing has been shared throughout the wider organisation to ensure that the learning from the incident has been communicated and lessons learnt across the Trust.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Implement monthly caseload-management supervision supported by an electronic caseload dashboard and review of essential care documents.
Verbatim wording from the response “As a Trust we recognise that staff need support in managing their caseload and an integral part of this is effective caseload management supervision. In addition, caseload oversight follows the patient pathway so that our response remains central to a patient’s need, whilst also ensuring the right staff have the right skills to offer at the right time to promote recovery. For these reasons the Trust implemented a new Caseload Management Supervision Policy in January 2023 following a successful pilot in the last quarter of 2022. This policy ensures that monthly caseload supervision is completed, the use of an electronic caseload dashboard to facilitate and highlight areas of supervision and time to consider the quality of essential care documents.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 an escalation procedure to obtain senior-management intervention and deploy staff or managers when crisis assessments risk breaching timescales.
Verbatim wording from the response “Additionally, the Crisis Team have introduced an escalation procedure to ensure that if there is a concern that an assessment would not be undertaken within the given timescales, that this is discussed with senior management. Arrangements will then be made to ensure that assessments are not delayed which can include deploying staff resource from other teams, and management stepping into clinical roles.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Allocate safeguarding-team links to clinical areas to provide safeguarding support and guidance.
Verbatim wording from the response “To strengthen safeguarding practices across the organisation, the Trust safeguarding team allocate members of the team to link in with different clinical areas across the Trust. This provides increased support and guidance within the teams, enabling timely and effective handling of safeguarding concerns. The organisation has also issued a Patient Safety Briefing following this incident, this briefing has been shared throughout the wider organisation to ensure that the learning from the incident has been communicated and lessons learnt across the Trust.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 on completing safety summaries and safety plans to crisis staff.
Verbatim wording from the response “In evidence, ████████ confirmed that work had been undertaken by the Trust to ensure that safety plans were completed. ████████ indicated that a monthly audit was in place to check compliance with the completion of safety plans and summaries.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Discuss safeguarding concerns daily in community and crisis huddles, assign actions, and share incident learning and review findings with teams.
Verbatim wording from the response “As a Trust we are committed to learning from this incident and have implemented the necessary improvements to prevent such incidents from happening in the future. Safeguarding concerns are now a standard agenda item discussed daily within community and crisis huddles, attended by all members of the multi-disciplinary team. Any identified actions are promptly acted upon, with individual clinicians taking responsibility for allocated tasks. The learning in relation to this incident has been discussed within team meetings, and the review from the incident has been shared with the team to ensure widespread awareness.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Check and discuss every patient’s safety summary and safety plan during daily Crisis Team huddles, assigning required updates.
Verbatim wording from the response “As part of the Crisis Team’s daily huddle, every patient’s care is discussed. As part of the huddle safety summaries and safety plans are checked and discussed as a multi-disciplinary team. Any changes or updates that are required are identified and staff are tasked to complete these.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Audit triage-tool use and documentation monthly through QA5 and review compliance in clinical supervision and quality-assurance processes.
Verbatim wording from the response “████████ confirmed that a monthly audit was undertaken to monitor the use of the triage tool, as well as case management supervision with clinicians, reviewing that this had been completed. Supervision is carried out on a quarterly basis in line with the Trust Supervision Policy. As part of the development work, discussions were held with all staff within supervision regarding the use of the tool and triage documentation.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 regular bespoke safety-summary and safety-plan training, including training for new team members.
Verbatim wording from the response “In both teams, bespoke safety summary and safety plan training, that is supplementary to mandatory harm minimisation training, is delivered and allows for exploration of specific risks and scenarios related to their service provision. This training is a regular offer within the teams and is completed as part of the induction of new staff into the team.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 additional training on the Parental Mental Ill Health and Children tool to support safeguarding-referral decisions.
Verbatim wording from the response “In evidence, ████████ confirmed that since this incident, staff have received additional training in relation to the Parental mental ill health on children tool (PAMIC). ████████ confirmed that the tool considers how a parent’s mental health may impact on a child and supports the clinician completing the tool to consider whether a referral to the local authority for safeguarding teams should be completed and actions that should be considered to safeguard the child/children.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Enhance QA5 auditing to assess PAMIC completion, safeguarding identification, and completion of appropriate safeguarding actions.
Verbatim wording from the response “To provide assurance and to maintain consistent monitoring across the organisation, the Trust has enhanced its quality assurance schedule and has introduced the QA5 audit detailed earlier in this response. A recent addition to the audit tool includes reviewing compliance against PAMIC tool completion, whether a safeguarding concern has been identified in the past month, and whether appropriate actions have been undertaken when a safeguarding concern has been identified. This audit helps us to ensure agreed policies and procedures are being followed and to take corrective action where necessary to ensure safeguarding procedures are being followed.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 crisis-service staffing daily, attend safe-staffing meetings, and identify alternative resources during increased acuity.
Verbatim wording from the response “In evidence, ████████, speaking to ████████ statement, confirmed that during known periods of high demand, additional staffing is provided to ensure that targets are achieved. However, we acknowledge that crisis service acuity can be unpredictable, and may change from day to day.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 Monitor urgent-referral response compliance through weekly reporting, governance review, monthly specialty reporting, and Care Group escalation.
Verbatim wording from the response “There are examples where response times are breached due to patient preference for appointment times or venues and this is supported by the risk assessment and safety planning approach detailed above. Breaches are also recorded when teams are unable to locate service users post-triage and/or they do not attend their appointment. There are weekly reporting processes in place to monitor responses to very urgent referrals which allows for clinical oversight of decision making, target compliance and support allocation of any additional resource or intervention if required. Any breaches and compliance with the standards are monitored through our governance structures, reported monthly within Specialty Governance meetings and escalated through to the Care Group.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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 an escalation procedure requiring delayed-assessment concerns to be discussed with senior management and resourced through redeployment or management clinical support.
Verbatim wording from the response “Additionally, the Crisis Team have introduced an escalation procedure to ensure that if there is a concern that an assessment would not be undertaken within the given timescales, that this is discussed with senior management. Arrangements will then be made to ensure that assessments are not delayed which can include deploying staff resource from other teams, and management stepping into clinical roles.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Implement monthly caseload-management supervision and an electronic caseload dashboard to identify supervision needs and review essential care documents.
Verbatim wording from the response “As a Trust we recognise that staff need support in managing their caseload and an integral part of this is effective caseload management supervision. In addition, caseload oversight follows the patient pathway so that our response remains central to a patient’s need, whilst also ensuring the right staff have the right skills to offer at the right time to promote recovery. For these reasons the Trust implemented a new Caseload Management Supervision Policy in January 2023 following a successful pilot in the last” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 additional training for crisis staff on completing safety summaries and safety plans.
Verbatim wording from the response “In evidence, ████████ confirmed that work had been undertaken by the Trust to ensure that safety plans were completed. ████████ indicated that a monthly audit was in place to check compliance with completion of safety plans and summaries.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 safeguarding concerns a daily community and crisis-huddle agenda item, assign resulting actions and share incident learning with teams.
Verbatim wording from the response “As a Trust we are committed to learning from this incident and have implemented the necessary improvements to prevent such incidents from happening in the future. Safeguarding concerns are now a standard agenda item discussed daily within community and crisis huddles, attended by all members of the multi-disciplinary team. Any identified actions are promptly acted upon, with individual clinicians taking responsibility for allocated tasks. The learning in relation to this incident has been discussed within team meetings, and the review from the incident has been shared with the team to ensure widespread awareness.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Induct current and new crisis-team practitioners in crisis processes, triage-tool use and the rationale for senior-practitioner triage.
Verbatim wording from the response “In evidence, HMC heard evidence from ████████ that development work had been undertaken in the Durham and Darlington area in relation to the triage tool assessment process and staff development.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Issue and disseminate a Patient Safety Briefing on the incident’s safeguarding learning across the organisation.
Verbatim wording from the response “To strengthen safeguarding practices across the organisation, the Trust safeguarding team allocate members of the team to link in with different clinical areas across the Trust. This provides increased support and guidance within the teams, enabling timely and effective handling of safeguarding concerns. The organisation has also issued a Patient Safety Briefing following this incident, this briefing has been shared throughout the wider organisation to ensure that the learning from the incident has been communicated and lessons learnt across the Trust.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Expand QA5 audits to review PAMIC completion, safeguarding identification and completion of appropriate safeguarding actions.
Verbatim wording from the response “To provide assurance and to maintain consistent monitoring across the organisation, the Trust has enhanced its quality assurance schedule and has introduced the QA5 audit detailed earlier in this response. A recent addition to the audit tool includes reviewing compliance against PAMIC tool completion, whether a safeguarding concern has been identified in the past month, and whether appropriate actions have been undertaken when a safeguarding concern has been identified. This audit helps us to ensure agreed policies and procedures are being followed and to take corrective action where necessary to ensure safeguarding procedures are being followed.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Allocate safeguarding duty workers to provide immediate advice and support during core working hours.
Verbatim wording from the response “Additionally, to provide immediate support and advice during core working hours, the Trust have allocated safeguarding duty workers. This professional lead is available to discuss any safeguarding concerns and to offer guidance on how to address concerns safely, ensuring a child’s welfare remains a central priority. Outside of regular working hours, the Trust safeguarding policy directs staff to contact the local authority safeguarding team to ensure that concerns are promptly discussed and addressed as required.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Apply the national triage tool to new or otherwise eligible crisis-service patients and develop interim safety plans with patients and carers.
Verbatim wording from the response “For all new patients and those individuals not open to other secondary mental health services, the UK national triage tool is undertaken to initially triage and assess the patient and to agree the priority of assessment. This is in line with national standards set out by NHS England. The clinician carrying out the triage assessment will develop a safety plan, in discussion with the patient and their family/carer, to ensure the patient is safely supported until the crisis assessment takes place. If an immediate response is required due to an imminent safety or wellbeing concern this would be requested through 999 emergency services in line with national guidance.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Check and discuss every patient’s safety summary and safety plan during daily Crisis Team huddles, assigning staff to complete required updates.
Verbatim wording from the response “As part of the Crisis Team’s daily huddle, every patient’s care is discussed. As part of the huddle safety summaries and safety plans are checked and discussed as a multi-disciplinary team. Any changes or updates that are required are identified and staff are tasked to complete these.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Conduct monthly QA5 audits of safety-summary and safety-plan quality, risk mitigation documentation and completion, with corrective action and clinical supervision where needed.
Verbatim wording from the response “Monthly QA5 audits are conducted in accordance with the Trust Quality Assurance schedule. The tool asks questions about the quality of the safety summary and if it reflects the patient’s current level of risk. The tool also reviews if it is documented appropriately as to how these risks will be mitigated and managed within the safety plan. Audits continue to show sustained improvement in the completion of safety summaries and safety plans including the quality of these documents. They allow an opportunity for timely corrective actions where required and live supervision for clinicians.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Report and govern very-urgent referral response compliance through weekly monitoring, monthly specialty governance reporting and Care Group escalation.
Verbatim wording from the response “There are examples where response times are breached due to patient preference for appointment times or venues and this is supported by the risk assessment and safety planning approach detailed above. Breaches are also recorded when teams are unable to locate service users post-triage and/or they do not attend their appointment. There are weekly reporting processes in place to monitor responses to very urgent referrals which allows for clinical oversight of decision making, target compliance and support allocation of any additional resource or intervention if required. Any breaches and compliance with the standards are monitored through our governance structures, reported monthly within Specialty Governance meetings and escalated through to the Care Group.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Arrange for crisis clinicians to attend Connecting with People suicide-awareness training.
Verbatim wording from the response “All staff complete the Trust mandatory Harm Minimisation training. This training supports clinicians to develop skills and competence in the completion of person-centred safety plans that look at a range of risk factors when safety planning. Additionally, the crisis service is arranging for crisis clinicians to attend the non-mandatory “Connecting with People” suicide awareness training.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 regular bespoke safety-summary and safety-plan training, including training during induction for new team staff.
Verbatim wording from the response “In both teams, bespoke safety summary and safety plan training, that is supplementary to mandatory harm minimisation training, is delivered and allows for exploration of specific risks and scenarios related to their service provision. This training is a regular offer within the teams and is completed as part of the induction of new staff into the team.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 Audit crisis-team triage-tool completion and quality monthly through QA5 and reinforce compliance through clinician supervision.
Verbatim wording from the response “████████ confirmed that a monthly audit was undertaken to monitor the use of the triage tool, as well as case management supervision with clinicians, reviewing that this had been completed. Supervision is carried out on a quarterly basis in line with the Trust Supervision Policy. As part of the development work, discussions were held with all staff within supervision regarding the use of the tool and triage documentation.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 crisis-service staffing daily, attend safe-staffing meetings and arrange alternative staffing support when demand threatens timely assessments.
Verbatim wording from the response “In evidence, ████████, speaking to ████████ statement, confirmed that during known periods of high demand, additional staffing is provided to ensure that targets are achieved. However, we acknowledge that crisis service acuity can be unpredictable, and may change from day to day.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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 additional staff training on the PAMIC tool to support recognition and referral of safeguarding concerns affecting children.
Verbatim wording from the response “In evidence, ████████ confirmed that since this incident, staff have received additional training in relation to the Parental mental ill health on children tool (PAMIC). ████████ confirmed that the tool considers how a parent’s mental health may impact on a child and supports the clinician completing the tool to consider whether a referral to the local authority for safeguarding teams should be completed and actions that should be considered to safeguard the child/children.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign safeguarding-team links to clinical areas to provide teams with additional safeguarding support and guidance.
Verbatim wording from the response “To strengthen safeguarding practices across the organisation, the Trust safeguarding team allocate members of the team to link in with different clinical areas across the Trust. This provides increased support and guidance within the teams, enabling timely and effective handling of safeguarding concerns. The organisation has also issued a Patient Safety Briefing following this incident, this briefing has been shared throughout the wider organisation to ensure that the learning from the incident has been communicated and lessons learnt across the Trust.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The crisis service cannot provide emergency responses because it is not commissioned or resourced and clinicians lack appropriate skills or legal frameworks.
Verbatim wording from the response “patient and to agree the priority of assessment. This is in line with national standards set out by NHS England. The clinician carrying out the triage assessment will develop a safety plan, in discussion with the patient and their family/carer, to ensure the patient is safely supported until the crisis assessment takes place. If an immediate response is required due to an imminent safety or wellbeing concern this would be requested through 999 emergency services in line with national guidance. As per the evidence of Ms Price, the crisis service is not commissioned or resourced to provide an emergency response and clinicians do not have the appropriate skills, and in many cases, a suitable legal framework to provide such a response.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Immediate responses to imminent safety or wellbeing concerns should be requested through 999 emergency services.
Verbatim wording from the response “patient and to agree the priority of assessment. This is in line with national standards set out by NHS England. The clinician carrying out the triage assessment will develop a safety plan, in discussion with the patient and their family/carer, to ensure the patient is safely supported until the crisis assessment takes place. If an immediate response is required due to an imminent safety or wellbeing concern this would be requested through 999 emergency services in line with national guidance. As per the evidence of Ms Price, the crisis service is not commissioned or resourced to provide an emergency response and clinicians do not have the appropriate skills, and in many cases, a suitable legal framework to provide such a response.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Immediate emergency responses are requested through 999 emergency services in line with national guidance.
Verbatim wording from the response “For all new patients and those individuals not open to other secondary mental health services, the UK national triage tool is undertaken to initially triage and assess the patient and to agree the priority of assessment. This is in line with national standards set out by NHS England. The clinician carrying out the triage assessment will develop a safety plan, in discussion with the patient and their family/carer, to ensure the patient is safely supported until the crisis assessment takes place. If an immediate response is required due to an imminent safety or wellbeing concern this would be requested through 999 emergency services in line with national guidance.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The crisis service cannot provide emergency responses because it is not commissioned or resourced, and lacks appropriate skills and, often, legal authority.
Verbatim wording from the response “As per the evidence of ████████, the crisis service is not commissioned or resourced to provide an emergency response and clinicians do not have the appropriate skills, and in many cases, a suitable legal framework to provide such a response.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
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