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. 28
Royal Devon University Healthcare NHS Foundation Trust Deliver regular Mental Health Act training to Emergency Department, Site Management, medical and foundation doctor staff.
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Royal Devon University Healthcare NHS Foundation Trust Train volunteer clinicians as Mental Health Champions through a five-day programme.
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Royal Devon University Healthcare NHS Foundation Trust Conduct a training needs analysis to determine further training requirements, target areas and appropriate staff levels.
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Royal Devon University Healthcare NHS Foundation Trust Consider distributing Mental Health Act information leaflets with staff payslips.
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Royal Devon University Healthcare NHS Foundation Trust Deliver monthly full-day Dementia and Delirium training to registered and non-registered staff.
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Royal Devon University Healthcare NHS Foundation Trust Train a specialist nursing staff pool for dedicated mental health input, reducing reliance on agency staff.
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Royal Devon University Healthcare NHS Foundation Trust Deliver a package on managing challenging behaviour and using rapid tranquillisation as a last resort to medical ward staff.
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Devon Partnership NHS Trust Raise inpatient bed-capacity and patient-safety risks with commissioners through contract monitoring and formal Board-level correspondence.
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Devon Partnership NHS Trust Secure temporary additional contracted out-of-area bed capacity.
View source
Devon Partnership NHS Trust Establish a central Trust-wide bed-management team to proactively manage and secure beds.
View source
Devon Partnership NHS Trust Deliver recurring Liaison Psychiatry training to general-hospital staff, including Emergency Department, site-management, medical-staff, foundation-doctor and Mental Health Champion sessions.
View source
Devon Partnership NHS Trust Roll out the newly developed challenging-behaviour and rapid-tranquilisation training package monthly.
View source
Devon Partnership NHS Trust Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
View source
Devon Partnership NHS Trust Develop further alternatives to acute admission, including improved community support and additional step-down provision.
View source
Devon Partnership NHS Trust Complete the Liaison Psychiatry teams’ PLAN self-review and undergo the scheduled final PLAN review.
View source
Devon Partnership NHS Trust Agree responsibility for streamlining social-care and continuing-healthcare funding applications and reviews.
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Devon Partnership NHS Trust Complete the Root Cause Analysis action and incorporate it into regular management supervision.
View source
Devon Partnership NHS Trust Monitor clinical documentation through line-management supervision and documentation audits.
View source
Devon Partnership NHS Trust Operate an embedded system directing Mental Health Act issues to site managers and provide rolling training for the site-management rota.
View source
Devon Partnership NHS Trust Deliver monthly full-day Dementia and Delirium training.
View source
Devon Partnership NHS Trust Provide temporary step-down care using spare recovery and rehabilitation ward capacity.
View source
Devon Partnership NHS Trust Share the coroner’s findings with the involved service and across the Trust.
View source
NHS Devon Integrated Care Board Work with Devon County Council on care-home commissioning and market sufficiency for older people.
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NHS Devon Integrated Care Board Participate in workshops mapping current and future discharge and panel-approval processes.
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NHS Devon Integrated Care Board Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
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NHS Devon Integrated Care Board Offer DPT additional management and consultative support from the urgent-care commissioning team.
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NHS Devon Integrated Care Board Lead work with Devon County Council to streamline joint-funding approval processes and develop a simplified section 117 aftercare funding agreement.
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NHS Devon Integrated Care Board Monitor delayed-discharge performance through regional board oversight and the DPT contract review meeting.
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× 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 available psychiatric inpatient beds
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds . The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one , but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients, and it is acknowledged that this is a wider issue of social and community care and resources. This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” 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 correctly apply the Mental Health Act in physical care environments
Wider context from the report “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve", although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment , which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
” 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 Delays in discharge caused by inadequate social and community care resources
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds. The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients , and it is acknowledged that this is a wider issue of social and community care and resources . This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” 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 adequate mental health training for physical healthcare staff
Wider context from the report “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve" , although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment, which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
” 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 Deliver regular Mental Health Act training to Emergency Department, Site Management, medical and foundation doctor staff.
Verbatim wording from the response “Part of the role of the DPT Liaison Psychiatry team is to offer training to colleagues in the acute hospital. This is done both formally and informally. In 2016, the Liaison Psychiatry Team has formally trained at least 496 staff, having taught 175 teaching sessions.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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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 volunteer clinicians as Mental Health Champions through a five-day programme.
Verbatim wording from the response “• Mental Health Champion Training (x5 full days) to RD&E clinicians who have volunteered themselves as Mental Health Champions for the RD&E. This helps support staff with patients in practice.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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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 Conduct a training needs analysis to determine further training requirements, target areas and appropriate staff levels.
Verbatim wording from the response “With regards to future development, there is a general consensus that a greater awareness and understanding of the MHA would be beneficial to all staff. Ensuring that this training is of a suitable level, proportionate and appropriate to staff grading is essential. We are looking at the best ways to target resources most effectively and efficiently.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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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 Consider distributing Mental Health Act information leaflets with staff payslips.
Verbatim wording from the response “Consideration is also being given to the viability a ‘leaflet drop’ with payslips. This has recently been done by the Child Protection/Safeguarding Team to good effect. This would ensure that all staff in all grades and positions have some basic training and an information resource on the MHA. Further ‘catch all’ training may also include information being added the RD&E intranet as a must-read document. It is hoped that the new ‘Mental Health Champions’ being trained could assist with any new training.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver monthly full-day Dementia and Delirium training to registered and non-registered staff.
Verbatim wording from the response “• A full days training on Dementia & Delirium once monthly for registered and non-registered staff” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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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 a specialist nursing staff pool for dedicated mental health input, reducing reliance on agency staff.
Verbatim wording from the response “Further, the RD&E is training a specialist pool of nursing staff for specific mental health input. This will lessen the need to use agency staff. This will allow the Trust to have better control over the training and expertise of the specialist mental health staff. It will also improve communication between the physical and mental health care professionals.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a package on managing challenging behaviour and using rapid tranquillisation as a last resort to medical ward staff.
Verbatim wording from the response “• A whole day’s package has just been built and is due to start being delivered later this month called “Management of Challenging Behaviour – Using Rapid Tranquilliser as a last resort” – this refers to use of the MHA in its content. This is being delivered to the medical wards and targeted at registered and non-registered staff where patients with mental health needs alongside physical needs are being nursed.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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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 Raise inpatient bed-capacity and patient-safety risks with commissioners through contract monitoring and formal Board-level correspondence.
Verbatim wording from the response “The Trust is acutely aware of the pressure upon our available bed stock and has raised the issue with our commissioners through both our contract monitoring meetings and via a formal letter from our Board level clinicians highlighting the very real risk to patient safety.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Secure temporary additional contracted out-of-area bed capacity.
Verbatim wording from the response “We now have in place a central trust wide bed management team to proactively manage and secure beds for those in need as quickly as we possibly can. We have temporarily secured additional contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than rely on ad hoc arrangements as we are in competition with other NHS providers for private beds.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a central Trust-wide bed-management team to proactively manage and secure beds.
Verbatim wording from the response “We now have in place a central trust wide bed management team to proactively manage and secure beds for those in need as quickly as we possibly can. We have temporarily secured additional contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than rely on ad hoc arrangements as we are in competition with other NHS providers for private beds.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Deliver recurring Liaison Psychiatry training to general-hospital staff, including Emergency Department, site-management, medical-staff, foundation-doctor and Mental Health Champion sessions.
Verbatim wording from the response “As described by our Liaison Psychiatry Clinical Team Leader during the inquest we have continued to support the training of the staff within the RD&E, I have described below the general role of the Liaison Psychiatry Team in training and the specific work undertaken during the last year.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Roll out the newly developed challenging-behaviour and rapid-tranquilisation training package monthly.
Verbatim wording from the response “• A full day package has just been developed called ‘Management of Challenging Behaviour – Rapid Tranquilisation - a last resort!’ and this began monthly roll-out in March 2017, this refers to use of the MHA and Mental Capacity Act in its content.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
Verbatim wording from the response “We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Develop further alternatives to acute admission, including improved community support and additional step-down provision.
Verbatim wording from the response “We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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 Complete the Liaison Psychiatry teams’ PLAN self-review and undergo the scheduled final PLAN review.
Verbatim wording from the response “The Liaison Psychiatry teams in Exeter have recently completed the self-review within the Psychiatric Liaison Accreditation (PLAN) process. PLAN is an initiative of the College Centre for Quality Improvement. PLAN works with services to assure and improve the quality of psychiatric liaison in hospital settings. PLAN engages staff and patients in a comprehensive process of review, through which good practice and high-quality care are recognised and services are supported to identify and address areas for improvement. Accreditation assures staff, patients and carers, commissioners and regulators of the quality of the service provided. PLAN includes core areas common for all teams, such as assessment and care planning. Record keeping is an essential part of this process and is scrutinized by completion of a case note audit.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Agree responsibility for streamlining social-care and continuing-healthcare funding applications and reviews.
Verbatim wording from the response “We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Complete the Root Cause Analysis action and incorporate it into regular management supervision.
Verbatim wording from the response “The Trust has in collaboration with the Royal Devon and Exeter NHS Foundation Trust (RD&E) undertaken a Root Cause Analysis Investigation following the death of Wendy; the report was shared at the inquest and I can confirm that the action for Devon Partnership Trust resulting from the report has been completed and is now part of regular management supervision.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Monitor clinical documentation through line-management supervision and documentation audits.
Verbatim wording from the response “Accurate and detailed records should be maintained at all times in accordance to DPT policy, & MNC responsibilities and regulations. | Standards of documentation particularly relating to recording of telephone conversations and multidisciplinary discussions were not recorded robustly within the clinical records. | Monitored by the CTL via line management supervision systems and documentation audits. | Clinical Manager Liaison Psychiatry Team. | 31/01/17” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Operate an embedded system directing Mental Health Act issues to site managers and provide rolling training for the site-management rota.
Verbatim wording from the response “We agreed that wider training across the hospital for nurses and medical staff was unrealistic given that the majority of staff would only come into contact with the Act infrequently, we agreed that all the training and expertise would be held by the site management team and our MHA office and liaison team regularly meet the site manager to discuss incidents, share learning, update in relation to any amendments to the Act and deliver rolling training to the site managers who run a 24 hour, 7 day a week rota across the whole hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Deliver monthly full-day Dementia and Delirium training.
Verbatim wording from the response “• Dementia & Delirium full days training once a month.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 temporary step-down care using spare recovery and rehabilitation ward capacity.
Verbatim wording from the response “We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Share the coroner’s findings with the involved service and across the Trust.
Verbatim wording from the response “Thank you for your letter of 15 February 2017 which we received on the 17 February 2017 following the inquest into the death of Wendy Louise Telfer. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Devon County Council on care-home commissioning and market sufficiency for older people.
Verbatim wording from the response “9. NEW Devon CCG is working closely with Devon County Council with regard to care home commissioning and market sufficiency for older people.” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in workshops mapping current and future discharge and panel-approval processes.
Verbatim wording from the response “5. NEW Devon CCG, with Devon County Council representatives have participated in a series of workshops facilitated by DPT aimed at mapping current and future discharge and panel approval processes. NEW Devon CCG is awaiting the final report and recommendations for improvement in these processes from DPT;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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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 Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
Verbatim wording from the response “7. DPT have indicated a need for additional step down beds to be made available in the Exeter area and NEW Devon CCG is working with DPT to identify solutions for this need;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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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 Offer DPT additional management and consultative support from the urgent-care commissioning team.
Verbatim wording from the response “8. NEW Devon CCG has offered DPT additional management and consultative support from its urgent care commissioning team who have had success in working with acute hospital providers to reduce delays in discharge;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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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 Lead work with Devon County Council to streamline joint-funding approval processes and develop a simplified section 117 aftercare funding agreement.
Verbatim wording from the response “6. NEW Devon CCG is already leading a process, working in partnership with Devon County Council to streamline current processes for the approval of joint funding of s117 aftercare and are working towards a simplified s117 aftercare funding agreement;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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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 Monitor delayed-discharge performance through regional board oversight and the DPT contract review meeting.
Verbatim wording from the response “Monitoring of timely discharge performance data” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-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 Existing escalation arrangements require staff to seek specialist psychiatric advice and remain the Trust’s first-line approach for future Mental Health Act concerns.
Verbatim wording from the response “All of the current MHA training requests that if staff have any concerns about a patient’s mental health, then they should contact the specialist Psychiatric Liaison Team for advice on how to manage that patient in normal working hours and the psychiatric on call Crisis Team out of hours. The escalation process also includes contacting the Devon Partnership Trust on call team both in and out of hours if an issue is unresolved. The next stage of the process includes contacting the Devon Partnership Trust on-call Director if required. This is what is practiced throughout the RD&E at the moment. This would also be our first line of advice in any future training.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Devon Partnership Trust is responding separately to the other issues raised in the Prevention of Future Deaths report.
Verbatim wording from the response “In my response, I will address your first matter of concern. I understand that Devon Partnership Trust (DPT) is responding to you separately on the issues raised.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-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 Specialist assessments and advice did not support detaining the patient under the Mental Health Act when she attempted to leave.
Verbatim wording from the response “With respect to Wendy Telfer’s case, she had been formally assessed on two occasions by specialist practitioners from the DPT and they did not consider she should have been under a formal MHA section. On the day of her discharge, there was some uncertainty about her MHA status and her current presenting symptoms. Therefore, RD&E staff sought specialist advice from the Psychiatry Liaison Team on two separate occasions. They were not advised to use the MHA to detain the patient if she tried to leave. It was on the basis of this specialist advice that she was allowed to leave.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-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 Financial pressures and reduced staff availability constrain the Trust's ability to secure additional inpatient capacity.
Verbatim wording from the response “I think it is important to note that securing additional capacity is compounded by both the ever tightening financial position of our commissioners, ourselves and the reducing availability of staff across the country. I would very much like to assure you that we as a Trust are doing everything we can to use our available resources in the most efficient way we can to meet the increasing demand we are facing. I would also like to assure you that we will always put the safety of our patients first and will continue to do our level best to ensure someone needing a bed is provided with one as soon as we are able to source either internally or externally via the private sector.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-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 Wider Mental Health Act training for hospital staff is considered unrealistic because most staff encounter the Act infrequently.
Verbatim wording from the response “We agreed that wider training across the hospital for nurses and medical staff was unrealistic given that the majority of staff would only come into contact with the Act infrequently, we agreed that all the training and expertise would be held by the site management team and our MHA office and liaison team regularly meet the site manager to discuss incidents, share learning, update in relation to any amendments to the Act and deliver rolling training to the site managers who run a 24 hour, 7 day a week rota across the whole hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-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 Mental Health Act expertise is held centrally, with site-manager training and liaison support considered an effective hospital-wide arrangement.
Verbatim wording from the response “We agreed that wider training across the hospital for nurses and medical staff was unrealistic given that the majority of staff would only come into contact with the Act infrequently, we agreed that all the training and expertise would be held by the site management team and our MHA office and liaison team regularly meet the site manager to discuss incidents, share learning, update in relation to any amendments to the Act and deliver rolling training to the site managers who run a 24 hour, 7 day a week rota across the whole hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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