MEETING NOTES Mental Health Patient Safety Expert Group Held on 29 th June 2015 at Skipton House Attendees: Dr Ben Thomas - Professional Adviser for Learning Disabilities, Mental Health and Dementia Care, Department of Health (Chair) Vanessa Gordon - Patient Safety Head, NHS England Fiona Grossick - National Patient Safety and Clinical Quality Lead, Health & Justice, NHS England Sarah Markham - Expert Representative, Patient and Public Voice Ursula Rolfe - College of Paramedics Caroline Hacker - Head of Mental Health Policy Team, CQC Joanne McDonnell Senior Nurse for Mental Health and Learning Disabilities, NHS England Michelle Anstiss - Safety & Learning Lead, NHS Litigation Authority (NHS LA) Ros Alstead, Director of Nursing and Clinical Standards, Oxford Health NHS Foundation Trust Carol Boreham Patient Safety Reporting Lead, National Recording and Learning System Althea Baker note taker Lorna Grell (observer) NHS England Nina Ahmadi (observer) Department of Health Apologies: Louis Appleby - Professor of Psychiatry, National Suicide, Prevention, Strategy Advisory Group Ray Walker - Executive Director of Nursing, Mersey Care NHS Trust Ian Hulatt - Mental Health Adviser, Royal College of Nursing Malcolm Alexander - Action Against Medical Accidents (AvMA) Sophie Corlett, Director of External Relations Alan Worthington - Carer Champion Jenny Rees Head of Rights and Responsibilities Equality, Rights and Decency Group National Offender Management Service
A Introductions and apologies While Paul Farmer is heading up the MH Taskforce, BT is interim Chair. Caroline Hacker and Ursula Rolfe were welcomed to their first meeting. B Notes from the last meeting Restraint events were held and since 1 April, data has been captured in returns. Some incidents of restraint have been recorded as No harm but free text states patient hurt. Data mainly from Acute Trusts - 154 returns mixture of A&E and MH patients. Mental Health Trusts reporting harm is low still issues about double reporting. Interpretation of Restraint is variable need clarity around the definition. Also need to agree how to report back to DH on collated data. Is there assurance in the system that patients who are harmed through restraint are followed up? Safety concerns go back to NHS providers through Regional Safety Leads. Need to ensure non-reporters are followed up. NRLS is encouraging MH Trusts to hare good practice through Forums. VG and CB to provide report for DH s Positive and Safe Group in 2 weeks. Include examples/grading of harm and next steps FG to follow up with Prison Healthcare and report back CB to include clearer definition of restraint in NRLS Newsletters CH to share CQC inspection findings with NRLS to develop consistency By 17 July BT reported that Learning Disabilities restraint meetings arranged for CCGs across England can include Mental Health on the agenda. Physical observations after restraint Still difficult to get take up. Minimal guidance from NHS England for clinicians to action. Trusts can put in policy with expected standards. Patient Safety team alert ready and can supplement NICE s guidance on Violence and aggression: short-term management in mental health, health and community settings. At next PSEG Chairs meeting, BT to recommend to Mike Durkin that the alert be sent to encourage good practice around physical observations 21 July BT to find out what checks are made at Trusts who have good results on physical observations Prescribing and self-harm VG thought the Medical PSEG had sent a letter to the Department of Health to ask if the amount of medication prescribed at any given time can be limited. VG to check with Medical PSEG about letter re limiting amount of medicines prescribed
Picking up prescriptions Meeting held with clinicians noted GP flagging system does not automatically assume MH patient (or any patient) is unwell if meds not collected. C Role and function of Expert Patient Safety Groups in NHS England Patient Safety function moving from NHS England. Timeline still not decided but agreement has been reached that the functions will remain within the Patient Safety remit. In preparation for the change, NHS England has been tracking all people with Learning Disabilities in NHS funded settings. However, as the 3 rd or Independent Sectors do not use NRLS, their numbers and/or levels of harm are unknown. D Update on Mental Health Patient Safety SM reported that her local Trust has been sending alerts about the dangers of Polypharmacy. JMcD noted that the Winterbourne View Medicines project report on Antipsychotic medication will be reporting in July. A letter will also be sent from Simon Stevens summarising the work done to date and next steps. CQC s report on Second Opinion Authorised Doctors has been delayed until September. E Mental Health Dashboard Dashboard in very early stages of development more work required. Need to be clear where the data is from, its reliability, and what the group should focus on to make the most impact. VG to contact PF to find out what further input on Dashboard is required from PSEG Mental Health Taskforce CH to provide more information on safety data collected/used by CQC for inspections Attendees have not been asked to submit evidence to the Taskforce and agreed that Geraldine Strathdee should be contacted for an update. This would be circulated to members before the next meeting. BT to write to Geraldine Strathdee asking for an update on the MH Taskforce s work F Mental Health homicides national actions/guidance Under the current Healthcare system, each NHS Region leads MH Homicides work. Governance arrangements differ but regions come together with the centre to discuss issues/findings. JMcD to keep group updated on MH homicides national actions
Commissioners use guidance published by National Patient Safety Agency (NPSA) in 2008 which is still the most current. Guidance to be circulated to the group. Trend analysis is done but inconsistently, which means national trends / issues can be overlooked. Work is being taken forward to ensure action and governance is more robust and consistent. Members agreed that learning from MH Homicides is a patient issue so should be discussed at meetings. Need to make the link between safer patient practices and governance so bringing trends/issues from regional reports to PSEG would be beneficial. FG suggested it would be sensible to have same criteria for MH settings and prisons. AB to circulate NPSA guidance with minutes Mental Health homicides national actions to be standing item on agendas G Supportive Observations The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) highlighted lack of therapeutic engagement when dealing with patients. Service users report one to one observations usually done by most junior member of staff, not someone they know/knows them. Should therapeutic engagement be part of Nursing training? Research shows observations are about physical environment/actions not how people are feeling/coping. Members agreed a review of practices could help improve competency levels of staff carrying out these observations. RA reported that AHSNs workstreams on mental health good would be a good source of evidence. BT, RA and JmD to consider what would be required to develop good supportive observations policies and practices VG to speak to Helen Smith and others to establish AHSNs remit BT speaking to CNO Scotland and MerseyCare about their experiences. H Any other business PSEG Membership Marion Janner has resigned. VG and PF wrote to thank her for her work with the group. Group now light on Expert by Experience, VG to follow up with Joan Russell. VG to speak to Joan Russell re recruitment of new Expert by Experience for MH PSEG Letter sent to Royal College of Psychiatrists asking for representative. No regional nurse representative. Geraldine unable to attend, ask to suggest a deputy to ensure medical engagement with the Group.
SI Framework VG suggested Lauren Mosley (Patient Safety Systems and Liaison Manager, NHS England) be invited to update the group on the Serious Incident Framework at the next meeting. Attendees agreed. SI Framework update to be item on next agenda AB to circulate SI Framework link to members VG to invite Lauren Mosley to present to the Group on Haelo 23 MH Trusts signed up. Patient Safety Tool; being piloted good feedback received. Hope to obtain gateway approval for September launch. National Patient Safety conference Being held 11 12 November. Will have a MH focus external partners have been notified and invited. Date of Next Meeting 8 th September, 9.30am 12.30pm, Room 133B, Skipton House, 80 London Road, London SE1 6LH