Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
× 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 Unavailability of psychological input to care planning
Wider context from the report “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning . The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.
” 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 continuity in treatment
Wider context from the report “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity . The responsible clinician was a locum who had recently taken over from another locum psychiatrist . There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.
” 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 Bed-availability pressure influencing section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the decision .
” 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 Absence of ward management leadership for care provision
Wider context from the report “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided . There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.
” 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 Incomplete nursing records
Wider context from the report “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete , possibly due to teething problems associated with the recently introduced electronic recording system .
” 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 notify police when a patient at suicide risk goes missing
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” Is this part of a recurring concern? Yes — Unreliable missing-person response .
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 evaluate a patient’s situation and required action after return to the ward
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him .
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 heed family warnings about a patient’s fitness for discharge
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded .
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 establish alternative accommodation and transition arrangements before discharge consideration
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised . In the absence of such transition infrastructure, it was premature to consider him for discharge from the section .
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 undertake a formalised mental capacity assessment before section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions .
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the decision.
” 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 sufficiently consider the significance of potential farewell behaviour
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered .
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 Use of a responsible clinician with insufficient role experience for section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks .
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the decision.
” 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 involve family in section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made .
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the decision.
” 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 update the care plan before section rescission
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated .
e. the pressure on bed availability in the Newsam Centre may have influenced the decision.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning through clinical governance and remind staff to document interventions in care plans and risk assessments.
Verbatim wording from the response “Mr Bastock was assessed by an Occupational Therapist as having the functional ability to return home and appropriate input was sought to help with this, including a referral to a social worker, allocation to a CPA care co-ordinator and ongoing contact with Caring for Life. Early input from the Intensive Support Service was arranged to help facilitate successful discharge. Unfortunately, these interventions to support Mr Bastock transition back home were not documented within his care plan or risk assessment. The learning from Mr Bastock’s case will be shared with the team through the Trust’s clinical governance structure and staff will be reminded of the importance of ensuring all interventions are documented. An audit of care plans will be undertaken monthly by the ward manager and the findings will be shared with the team via the local Clinical Improvement Forums.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review medical staff training provision on mental capacity assessments.
Verbatim wording from the response “To support an improvement in relation to this area, the Trust’s Head of Mental Health Legislation, in conjunction with the Medical Director, will carry out a review of the current training provision for medical staff in relation to mental capacity assessments.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Ensure Triangle of Care principles are enacted consistently for service users and family members.
Verbatim wording from the response “We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Use regular ward care-planning meetings to support consistent review and updating of care plans.
Verbatim wording from the response “meetings to support a consistent team approach to care plans ensuring that care plans are reviewed and updated appropriately.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the revised procedure’s return-interview requirements.
Verbatim wording from the response “The revised procedure will direct staff to ensure that a discussion or return interview will be held with service users upon their return to the ward following a period of unauthorised leave. This information should then inform the service user’s care plan with regards to directing staff what action to take in the event that a service user does not return from leave and future decision making with regards to agreeing leave. The Trust will audit our compliance against this aspect of the procedure in July 2022.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Undertake a Trust-wide audit of mental capacity assessments and best-interest decisions, including possible detention-rescission decisions.
Verbatim wording from the response “In January 2022, a Trust-wide audit relating to mental capacity assessments and best interest decisions will be undertaken. The Mental Health Legislation Team will review the audit tool to explore if the decision to rescind a detention can be incorporated within this audit.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Discuss amending the Responsible Clinician form to prompt documentation of mental capacity assessments when rescinding detention.
Verbatim wording from the response “A discussion will be held through the Trust’s Mental Health Legislation Operational Steering Group to amend the form completed by the Responsible Clinician when a decision to rescind the section is made, which will include a prompt for the Responsible Clinician to ensure that a mental capacity assessment is documented.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Ratify and disseminate the revised Missing Service User Procedure and adjust associated training as required.
Verbatim wording from the response “The Trust Missing Service User Procedure outlines the actions staff should take in the event a service user does not return to the ward. The Missing Service User Procedure, although led by the Trust is jointly agreed with West Yorkshire Police. Both organisations have taken a further review of the procedure to ensure it contains the learning from this incident. The draft procedure has been circulated to stakeholders for comment and will then be ratified and circulated by January 2022. The updated procedure will be disseminated to all staff via Trust wide email, and any required adjustments will also be made to any associated training.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and share Triangle of Care principles with staff to improve family and carer involvement.
Verbatim wording from the response “We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement return interviews after unauthorised leave and use the information to guide care plans and future leave decisions.
Verbatim wording from the response “The revised procedure will direct staff to ensure that a discussion or return interview will be held with service users upon their return to the ward following a period of unauthorised leave. This information should then inform the service user’s care plan with regards to directing staff what action to take in the event that a service user does not return from leave and future decision making with regards to agreeing leave. The Trust will audit our compliance against this aspect of the procedure in July 2022.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the induction package to formalise explicit, proportionate support and supervision for locum medics.
Verbatim wording from the response “The core professional standards require that any new Responsible Clinician has sufficient familiarity with a patient’s past and current history to support robust decision making. To ensure the Trust learns from the sad death of Mr Bastock, the Professional Medical Lead will formalise the support and supervision arrangements that are in place for locum medics by reviewing the current induction package to ensure support and supervision arrangements are explicit and proportionate.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise the Missing Service User Procedure to incorporate learning from the incident.
Verbatim wording from the response “The Trust Missing Service User Procedure outlines the actions staff should take in the event a service user does not return to the ward. The Missing Service User Procedure, although led by the Trust is jointly agreed with West Yorkshire Police. Both organisations have taken a further review of the procedure to ensure it contains the learning from this incident. The draft procedure has been circulated to stakeholders for comment and will then be ratified and circulated by January 2022. The updated procedure will be disseminated to all staff via Trust wide email, and any required adjustments will also be made to any associated training.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit care plans monthly and share development areas and good practice through local Clinical Improvement Forums.
Verbatim wording from the response “The words local system procedure outlines that care plans should be reviewed and updated weekly or if there are changes to a patient’s presentation. Mr Bastock’s care plan was updated to reflect his informal status however, no further updates were made. At the time of Mr Bastock’s admission, the Trust had transitioned to a new electronic care record system which is now robustly embedded across the organisation. From January 2022, an audit of care plans will be undertaken monthly and the findings including areas for development and good practice will be shared with the team via the local Clinical Improvement Forums. The ward has also embedded regular care planning” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Simplify the electronic care-planning document, develop supporting guidance, and provide staff support for implementing the revised care plan.
Verbatim wording from the response “Trust-wide, work is underway to simplify the existing care planning document on the electronic patient record. This will include a specifically designed in-patient care plan with a link to the FACE risk assessment. An initial draft of the care planning document will be shared through the Trust governance processes in January 2022. A guide is being developed to support staff in recording information consistently and this will include the level of engagement and agreement the service user had with each element of the care plan. Additional support will be given to staff to implement this new care plan effectively.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the clinical handover process for locum medics to support robust clinical decision-making.
Verbatim wording from the response “The Trust will also review their clinical handover process to ensure it supports robust clinical decision making when locum medics commence in post.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Rescinding detention was not premature discharge because the patient agreed to remain in hospital informally; discharge was not imminent.
Verbatim wording from the response “e. Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 A consultant psychologist was aligned to the ward and available to support clinical decision-making and care planning.
Verbatim wording from the response “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Rescinding detention did not discharge the patient or affect bed availability; discharge decisions are clinically based and not driven by resource pressures.
Verbatim wording from the response “e. The pressure on bed availability in the Newsam Centre may have influenced the decision.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ward was not without a ward manager; leadership continuity was maintained through handover and support from the outgoing manager.
Verbatim wording from the response “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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 Implement the leave-planning template across the service and audit its impact.
Stated by Leeds and York Partnership NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 4 November 2021. View source 2 Develop a service-wide template for planning and reviewing leave, including family input, previous leave, presentation, risks, and care-plan engagement.
Stated by Leeds and York Partnership NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 4 November 2021. View source 3 Develop an action plan incorporating the recommendations in the response and share it with the coroner.
Stated by Leeds and York Partnership NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 4 November 2021. View source 4 Provide additional leadership support to teams undergoing transitional periods.
Stated by Leeds and York Partnership NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 4 November 2021. View source 5 Maintain a Carer Champion role attending Triangle of Care steering meetings to share and monitor progress.
Stated by Leeds and York Partnership NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 4 November 2021. 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 Implement the leave-planning template across the service and audit its impact.
Verbatim wording from the response “The template will be implemented across the service following approval at the Service Clinical Improvement Forum in January 2022. The information gathered in the template will be used as part of the MDT meeting to inform decision making regarding ongoing care. It will also enable the team to review reoccurring concerns following periods of leave and consider if a patient is engaging with their current care plan. We will audit the impact of this change in practice in July 2022.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a service-wide template for planning and reviewing leave, including family input, previous leave, presentation, risks, and care-plan engagement.
Verbatim wording from the response “In addition to this, to ensure the Trust has learnt lessons from Mr Bastock’s death the Acute Inpatient Service have developed a template to support good practice around the planning and reviewing of leave and takes into consideration:
○ Involvement of families and carers in the decision to grant leave
○ Feedback from service users, families, and carers
○ Evaluation of previous leave
○ Changes to mental state and presentation
○ Any risks associated with ongoing leave
○ Ability of service user to engage with their personal care plan” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an action plan incorporating the recommendations in the response and share it with the coroner.
Verbatim wording from the response “To support the further learning that will take place, the Trust will be developing an action plan which will include all the recommendations provided within this response, we will of course share this with you. We would be pleased to provide any further information or clarification required. If you feel that a meeting with staff to discuss any of the above would be helpful, please do not hesitate to contact us.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Provide additional leadership support to teams undergoing transitional periods.
Verbatim wording from the response “can create an element of instability for both patients and staff, therefore, to ensure we learn from the death of Mr Bastock, the senior leadership team has met with teams to provide additional support to any areas that are undergoing a transitional period.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Maintain a Carer Champion role attending Triangle of Care steering meetings to share and monitor progress.
Verbatim wording from the response “We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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