THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Board Paper - Cover Sheet Date 25.01.2018 Lead Director Report Title Learning Disability Update Nursing and Patient Services Director Agenda Item A5(iii) Report Author Classification Mrs Helen Lamont, Nursing and Patient Services Director Ms Alison Forsyth, Learning Disability Liaison Nurse Ms Frances Blackburn, Deputy Director of Nursing and Patient Services (Freeman) NHS Unclassified Purpose (Tick one only) Approval Discussion For Information X Links to Strategic Objectives Links to CQC Domains/ Fundamental Standard(s) Identified Risk? (If yes, risk reference) Resource Implications Legal implications and equality and diversity assessment Benefit to patients and the public Report History Next steps To put patients and carers at the centre of all we do and to provide care of the highest standard in terms of both safety and quality. Relevant CQC Domains are: Are they safe? Are they effective? Are they responsive? Are they well led? No. No resource implications. CQC Regulations include: Regulation 9 Person Centred Care Regulation 11 Need for Consent Regulation 12 Safe Care and Treatment Regulation 13 Safeguarding Service Users from abuse and improper treatment This paper demonstrates the Trust takes seriously its legal duties in relation to individuals with a Learning Disability and provides assurance that the Trust is compliant with related Monitor and CQC requirements, and is continuing to progress this agenda. It also demonstrates commitment to the Equality Act 2010. Provide assurance that robust mechanisms are in place to identify and support individuals with a Learning Disability. Previous Board update July 2017 Trust Board to receive the briefing and note progress and endorse future developments
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST LEARNING DISABILITY UPDATE Agenda Item A5(iii) EXECUTIVE SUMMARY In July 2017, the Board was updated regarding the ongoing work of the Trust s Learning Disability Liaison Team and how they are instrumental in supporting and leading the Trust s response to national recommendations about caring for children, young people and adults with a learning disability. This paper provides a summary of their ongoing work and practice developments and provides assurance that the Trust is compliant with related Monitor and CQC requirements, and is continuing to progress this agenda. Recent work has focused on: Facilitating a review of the Emergency Department (ED) by a team of Health Quality Checkers from Skills for People (a local Health Checker organisation) which were piloting a tool being developed by the NHS England. Learning Disability Mortality Reviews and liaison with regional Clinical Commissioning Groups (CCG s) to understand how cross agency reviews will be co-ordinated. Exploring the hosting of a newly developed training post for a GP Post-CCT Fellowship - Learning Disabilities. Development of Great North Children s Hospital (GNCH) passport. Case studies also demonstrate the work of the Liaison Nurses and Clinicians across the Trust to ensure patients have excellent experiences and equity of access to care. This paper also identifies potential risks, the key ones being that the Trust fails to meet the needs of patients, or to provide appropriate reasonable adjustments for those with learning disability. The increasing workload of the Learning Disability Liaison Team is also highlighted as a challenge. RECOMMENDATIONS To i) receive the report and ii) note the progress made iii) endorse the ongoing work. Helen Lamont Nursing & Patient Services Director Alison Forsyth Learning Disability Liaison Nurse Frances Blackburn Deputy Director of Nursing and Patient Services (Freeman) 17 th January 2018
Agenda Item A5(iii) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST LEARNING DISABILITY PROGRESS REPORT 1. INTRODUCTION / BACKGROUND The Trust continues to develop practice to improve care for people with learning disabilities, building on the existing infrastructure and dedicated expertise of the Learning Disability Liaison Team. This has been sponsored by the Nursing and Patient Services Director, supported by the Learning Disability Steering Group, with operational leadership being effectively provided by the Deputy Director of Nursing and Patient Services (Freeman). On-going progress is evident and reported in this paper. In response to the report published by Sir Jonathan Michael, Healthcare for All (2008), the Care Quality Commission (CQC) requires Trusts to self-assess against six questions related to access to healthcare for people with a learning disability. The Trust continues to declare compliance with these standards via Monitor and to further enhance provision; the current position is detailed in Appendix One. The Trust continues to actively contribute to Regional work, including the North East and Cumbria Learning Disability Network. This paper provides the Board with an update on progress made within the last six months and a summary of further commitments proposed for 2018. 2. CQC REQUIREMENTS AND SIX LIVES PROGRESS In relation to the CQC requirements, work has been on-going within the Trust, with corporate leadership from Patient Services and progress can be demonstrated against each requirement, with the Trust being able to demonstrate achievement against all six recommendations (Appendix One). 3. IDENTIFICATION OF PATIENTS WITH A LEARNING DISABILITY The Trust continues to place a flag on a patient s electronic record when a clear diagnosis of learning disability is established. Numbers of flagged records continue to increase; currently 2378 patient records are flagged 340 children and 2038 adults. Total No. Flags Children Flags Adult Flags 1 st April 2017 2116 266 1850 1 st January 2018 2378 340 2038 % Difference 11.0% increase (262) 21.8% increase (74) 9.2 % increase (188) 1
There continues to be a substantial percentage increase of children being flagged which can be attributed to the focused work of the Learning Disability Liaison Team engaging with staff within the Children s Directorate. The Learning Disability Liaison Team facilitate awareness raising sessions within the Directorate mandatory study days to identify children and young people with learning disability as soon as a diagnosis has been established, thus ensuring provision of appropriate reasonable adjustments and equity of healthcare across their future life course. 4. LEARNING DISABILITY LIAISON NURSE UPDATE AND ACTIVITY The Learning Disability Liaison Team continues to support individual patients and families experience. Both nurses have an active caseload where they are directly involved in providing advice, negotiating reasonable adjustments, and liaising with other professional and care agencies. Examples of their work are demonstrated in the case studies at Appendix Two. Between 1 st April 2017 and 30 th November 2017 the service has received 1049 formal referrals. The data demonstrates that the Team is dealing with between 90 and 192 referrals per month. Of these more than half are generated automatically from the Trust ERecord sending alerts to the Team informing them of an admission or Emergency Department attendance. The other main reason for referral and requests is for facilitation of care, ranging from 50 to 111 referrals per month. This is a significant workload in terms of time as there can be complex and multiple discussions required (Appendix Two). This activity demonstrates both the need, value, and successes of the Learning Disability Liaison Nurses since the role was introduced in 2010. The clinical workload of the Team continues to increase, as more patients are flagged and people with a learning disability are living longer. The Team is under significant pressure to meet all patient needs alongside, audit of practice to provide assurance, and to progress practice development work. The team ethos is to support and empower clinical teams to meet needs with support initially, so they then can be confident in providing reasonable adjustment independently in the future. 5. PATIENT, CARER AND LEARNING DISABILITY LIAISON TEAM FEEDBACK The Trust continues to elicit patient feedback, from the patient, their carer or healthcare professional following attendances within the Trust, covering admissions to all sites for various interventions and attendances. The review of the Emergency Department detailed below elicited a range of feedback which has been shared with the department, examples of the feedback are noted: Positive feedback: I came by ambulance and the staff in A&E was all very nice and friendly. I felt reassured as they explained everything they were doing. Staff were trying to get in touch with my GP and Social Worker to discuss my support needs in the hospital. 2
The Doctor gave me plenty of time to process information and waited for my response. I found the service good. I feel I am treated with respect as a person in my own right. I and my staff would like to say thank you for your services. I was given a small room to wait in because of my seizures. Staff were kind and let me speak, they made me feel safe and let me talk to my partner to tell him how I was. Areas for reflection and learning were: One patient felt they had been rushed and not listened to by staff. I was not asked if it was a good idea if I went home after a small operation (same day) the Doctor was planning on sending me home. My support explained to the doctor about the support I needed and it was agreed I should stay overnight. The waiting time was a bit much for someone with a learning disability and onset of dementia. We waited for 10 hours. I found the waiting times long as I suffer from anxiety as well as other disabilities. I didn t really understand what the doctors were saying. I need help from someone to explain things in a way I can understand. This feedback reinforces that the ability to achieve effective communication is at the core of achieving a good patient experience and facilitating appropriate reasonable adjustments. The report including feedback has been shared with the Emergency Department Team and part of the action plan, as outlined below, will consider how this feedback is shared with frontline staff to support learning and future practice. 6. EMERGENCY DEPARTMENT HEALTH QUALITY CHECKERS REVIEW i) NHS England has commissioned a number of toolkits for use by local Health Quality Checkers. This is to establish how well health services support people with learning disabilities and the Trust has piloted the use of the tool for the Emergency Departments in partnership with Skills for People (local Health Checker organisation). The NHS Quality Checkers programme involves people with a learning disability employed to critically inspect local NHS services, to provide advice on how they can better meet their needs and those of other patients with additional needs. 3
Quality Checkers use their own experiences to make assessments on the quality of care and support, and to give a view that can be often missing from other forms of inspection. As people with a learning disability themselves they are best placed to identify the significant barriers they face when accessing NHS services, whether it is the use of complicated forms and language, confusing layouts of buildings, or staff who are not sure how to interact with people with additional needs. This all contributes to people with a learning disability being less likely to use services, which is a recognised issue which contributes to the health inequalities that people with a learning disability experience which needs to be addressed. The toolkit includes an initial self-assessment of the Emergency Department provision for people with learning disability, a visit to the Emergency Department by Quality Health Checkers and their supporter. The Health Quality Checkers used a range of methods to check the service such as; talking to staff and patients, observing what happens within the service and seeking views of users of the service. To seek views from service users they sent out 40 questionnaires to people with a learning disability who had attended ED, of which 12 were returned, they also arranged a focus group, but regrettably no one attended. ii) The report identified many positive areas within the Emergency Department in relation to its approach to patients with a learning disability this included: Access to the department was easy and it was felt to have good internal spaces for patients with a mobility problem. The department appeared calm and triage rooms were spacious clean and well lit. Safety was perceived to be taken very seriously. The Health Quality Checkers observed lots of fire safety information with clear exit signs. Staff wore name badges and it was easy to identify who was who in the Emergency Department. Department was seen to be clean, cleaning schedules were reassuring and they observed staff using gloves and aprons. Staff receive training in how to support patients who display challenging behaviour. Staff also have access to other professionals should they require further advice e.g. Psychiatric Liaison Team or the on call Learning Disability Psychiatrist. There is also a quiet room for patients to go to if needed. The Health Quality Checkers felt that all the staff they spoke with in the Emergency Department were very friendly. The Health Quality Checker s observed how staff spoke to patients and found them to be very respectful. Staff could tell them how they would support someone who was anxious or had challenging behaviours. 4
iii) Areas they have suggested we review and see if we can improve are: Signage signage is inconsistent with road signs referring to A&E whilst internal signage refers to Minor Injuries and Trauma and Emergency Centre. The use of the word Triage. Upon arrival at the department, there is a large sign that instructs people to go to Triage (the Health Quality Checker s pointed out that this assumes prior medical knowledge and is not pronounced how it is spelled, which could cause confusion). Triage is also hidden behind this sign it would not be obvious to go to this desk upon arrival. Language and font size of notices and departmental information on display could be improved to make it more accessible. The use of colour coded signs around the building was noted and the Health Quality Checkers felt this could be used more in the Emergency Department. Health Quality Checkers wondered how people with a learning disability who became agitated and distressed in the Emergency Department would be supported by security staff and what training these staff had received. There is an opportunity to increase awareness about the Specialist Learning Disability Liaison Nurses and their role. Have more easy read information available within the Emergency Department and displayed on the walls. Increase staff ability to use Makaton to help with communication. The Health Quality Checkers felt that the Quiet Room used has more than one single function and might be in use during busy times. A designated quiet room would be much better. Waiting times: could these be reduced for people with learning disabilities and/or autism, or at least can their wait take place in the quiet room. Could these patients be give a verbal explanation of how long they might have to wait and why, as it is difficult for them to understand information on screen/poster. Should more be done to ensure each person has someone with them (or the liaison staff) to make sure they understand the questions and choices they face, and the treatment proposed, and the service. iv) A number of recommendations were made within the report including: Review signage and the use of word Triage. The Emergency Department should ensure all signs are clear and not covered or hidden by other signs/objects. The Emergency Department should consider using footprints as a means of visually enabling people with learning 5
disabilities to navigate around the department. The words used should be easy to understand, or explained. The Emergency Department should look to producing easy read information regarding waiting times and how to explain this to patients. Have information about the Learning Disability Liaison service available within the Emergency Department and ensure the Volunteers are aware of this role. Review security staff training in how to support adults with Learning Disabilities or Autism who became agitated or distressed and may need to leave the waiting areas. The Trust should continue its good work with flagging, use of Health Passports, Liaison Nurses. The Trust should continue to provide training for staff about people with learning disabilities, including the contribution from an Expert by Experience. It might be helpful to involve a wider range of people with learning disability and/or autism in the training. Waiting times: could these be reduced for people with learning disabilities and/or autism, or at least can their wait take place in the quiet room. The Trust s Emergency Department Care Pathway already suggests these would be appropriate reasonable adjustments and we do see examples of this having been utilised in patient feedback but this was not evident to the Health Quality Checkers. v) Next Steps: The report has been shared with the Trust Executives and the Emergency Department Senior Management Team and following review and discussion an action plan will be developed to take the recommendations forward. Skills for People and the Health Quality Checkers would be happy to work with the Trust to look at better ways of engaging with patients and families, or to review our progress against these recommendations. This will require discussion to ascertain costs and potential priority areas to review. 7. CHILDREN S SERVICES The Learning Disability Liaison Team continues to work in partnership with the Children s Directorate to help identify children who have a clear diagnosis of a learning disability to enable a flag to be present on their e-records. This will ensure their pathways of care are reasonably adjusted to meet their individual needs, both for their current care in Children s Services, and throughout their life course and all future contact with Trust Services. In preparation for the identification of those Children and Young People with learning disabilities, the Learning Disability Liaison Team have worked in partnership with colleagues from the Children s Directorate in the development of 6
a visually aesthetic Young People s Hospital Passport which provides vital information to health professionals regarding the patient s individual needs. This is to be launched within the Great North Children s Hospital in early 2018. The Learning Disability Liaison Team are working with professionals from the Paediatric Medical Day Unit to develop a clear Day Case Pathway for a Child or Young Person with a Learning Disability from the learning points from case study (Appendix Two). 8. NORTH EAST AND CUMBRIA LEARNING DISABILITY CLINICAL NETWORK The Trust continues to be an active participant in the Network. The Network is funded through a regional subscription model and it has asked for confirmation that the Trust will continue with its contribution of 8K annually. Trust professionals are actively involved in two identified work streams: Support for expectant mothers with a learning disability and participation in two task and finish groups to develop a clear pathway pre-natal, birth and post-natal and the creation of consistent accessible information across the North East and Cumbria region. Further to the Tackling Inequalities for Children and Young People with Learning Disabilities Conference on 25 September 2017 the development of a family leaflet/resource across Cumbria and the North East that will cover issues such as flagging in primary and acute hospitals, being identified on learning disability registers, access to Annual Health Checks from age 14 etc. 9. GP POST-CCT FELLOWSHIP - LEARNING DISABILITIES The Trust has been approached to facilitate and host a newly developed GP Post- CCT Fellowship - Learning Disabilities training post. Nationally there has been an identified need for a new and different General Practitioner role capable of bridging the gap between primary and secondary care and physical health and learning disability. The post was advertised November 2017 and interviews were conducted mid December 2017, the Trust is awaiting the outcome. 10. LEARNING DISABILITY MORTALITY REVIEW Within the Trust all patients with learning disability who have died are discussed at the Trust Learning Disability Mortality Review Panel led by the Deputy Director of Nursing and Patient Services (Freeman), the Director of Quality and Effectiveness and Clinical Director of Quality and Safety, where further actions and the key learning points are explored and captured for sharing. From 1 st April until 31 st December 2017, 9 patients with a confirmed diagnosis of learning disability died within the Trust, however 2 would not fall within the 7
perimeters of the National Learning Disability Mortality Review (LeDeR) Programme (below the age of 4 years and both discussed within the child death review process). Of the 7 remaining deaths there were 2 male and 5 female. The age range varied from 17-72 years, the male mean age was 53 years and female 31 years. Their length of stay varied from 2 to 29 days. The majority were on the RVI site, attending via the Emergency Department. Just over 57% were residing outside of Newcastle, just over 57% within the family home. The most prevalent recorded cause of death was Pneumonia or brain injury due to cardiac arrest. All of the people reviewed had a number of co-morbidities. The Trust will continue to internally review all deaths of patients with learning disabilities. Following the introduction of the national LeDeR programme; all localities have been requested to discuss deaths within an external multi-agency framework. The governance arrangements are under the auspices of each individual CCG. The Trust recently organised a joint meeting for representatives of the North of Tyne and Gateshead CCGs and Acute providers to discuss cross boundary reviews, as many patients have care from different Trusts and may die in an organisation which is not within the CCG of their normal area of residence. The meeting was useful as it confirmed all organisations commitment to identifying and sharing learning and enabled discussion about some of the practical issues such as confirming who within an organisation would receive notification of a death or request for information and that a familiar Chronology template would be used to explore the care in the preceding 12 months initially. All organisations agreed to share their policies and examples of good practice especially in relation to involving families and carers. 11. RISKS AND RISK MITIGATION The key risks are that the Trust fails to: Meet its duty of care to effectively support patients with learning disabilities or to provide reasonable adjustments. Provide the necessary reassurance to the CQC. Maintain the momentum to identify patients with learning disabilities and, ensure that they follow pathways of care which are reasonably adjusted to meet their individual needs. Recognise the need to reiterate key messages and maintain education for staff. Continued funding support of involvement in the North East and Cumbria Learning Disability Clinical Network It is clear that all of the work described above provides significant mitigation of these risks; however more can always be done. Further work to be completed in 2018 to reduce the risks described includes: To develop with Emergency Department an Action Plan in response to the Emergency Department Health Quality Checkers review. 8
To continue to raise awareness of the importance of identification and flagging of children and young people with learning disabilities. Continue to gather feedback from patients and service users and carers to identify gaps. To showcase and share the exemplary work some of the Trust s clinical teams do in terms of provision of reasonable adjustments and to demonstrate across the Trust what is possible. Continuation of mortality reviews of patients with a learning disability who die whilst in Trust care and contribute to LeDeR reviews. Continuing the audit of documentation of best practice in relation to use of pathways of care, provision of reasonable adjustments to meet individual needs, hospital passports being utilised appropriately, and capacity assessment and consideration of Deprivation of Liberty Safeguards, if capacity is lacking. 12. SUMMARY The Trust is demonstrating achievement against all six CQC requirements and is now able to flag the patient record to alert professionals that patients have a learning disability. Protocols and pathways are present to ensure needs are met and are being integrated into Trust policy and practice. The role of Learning Disability Team is highly valued by patients, carers and Trust clinicians, and continues to lead the development of Trust systems, processes and staff education, all of which will help to ensure patients with a learning disability receive appropriate care. A review of Emergency Department by Health Quality Checkers has provided a useful perspective on facilities and information available to patients with a learning disability who attend the Emergency Department. It will be possible to take actions based on this report to make the experience better for both patients with and without a learning disability. The Trust is committed to working with other partners to ensure the needs of patients are met. Activity within the Learning Disability Team is growing year on year. This paper outlines the significant clinical caseload and associated workload of the Learning Disability Team. It highlights that there is always potential to do more to develop practice and staffs knowledge and skill in relation to Learning Disability, this leads to a substantial workload and pressure on the 1.8 WTE Learning Disability Liaison Nurses. Trust Board is asked to be cognisant of the pressure this Team is under. Meeting the needs of the clinical caseload is always prioritised and there is a concern that work to develop practice, review deaths and deliver training may be compromised or delayed. 9
13. RECOMMENDATION To i) receive the report and ii) note the progress made iii) endorse the ongoing work. Helen Lamont Nursing and Patient Services Director Alison Forsyth Learning Disability Liaison Nurse Frances Blackburn Deputy Director of Nursing and Patient Services (Freeman) 17 th January 2018 10
Appendix One CQC REQUIREMENTS CQC REQUIREMENT Does the Trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of care are reasonably adjusted to meet the health needs of these patients? TRUST ACTION/PROGRESS The Trust is able to identify people with a learning disability on e-record. Only patients with a confirmed diagnosis are flagged. The alerts audits have been developed to predict future weekly attendance of patients with learning disability. RAPPA Email alerts received by learning disability liaison service if patient with a learning disability dies to commence the mortality review process. The development of a virtual ward to identify all inpatient stays across the Trust. The Trust has demonstrated that it has successfully introduced Care Pathways which staff are using to identify individual needs and reasonably adjust care to meet those needs. Awareness raising within Children s services to identify children and flag e- records. In accordance with the Disability Equality Duty of the Disability Discrimination Act (2005), does the Trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria: treatment options (including health promotion) complaints procedures, and appointments Within the Trust intranet an easy read information page has been developed with a range of information including, Complaints, Mental Capacity Act Guidance and specific health leaflets e.g., Colonoscopy and MRSA. The Trust has purchased a number of Photosymbols 4 licenses to assist staff develop additional easy read information. A number of easy read leaflets have been developed including Cardiothoracic pre assessment, Hypertension Service, Colposcopy clinic and Emergency Department. All core Coming into Hospital leaflets have an Easy Read version. 11
Trusts has developed accessible films of Radiological Procedures for people with a LD and are available via Trust Intranet or as a DVD. DVD has been developed to explain the importance of the hospital passport. Does the Trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities, including the provision of information regarding learning disabilities, relevant legislation and carers rights? Does the Trust have protocols in place to routinely include training on learning disability awareness, relevant legislation, human rights, communication techniques for working with people with learning disabilities and person centred approaches in their staff development and/or induction programmes for all staff? North of Tyne LD Liaison Nurses have developed care pathways for paid and unpaid carers. A leaflet for carers of patient with a learning disability has been developed and to be presented to the Patient Information Review Panel. Staff Induction now includes information regarding Learning Disability within Safeguarding Adults Training. All E&D and HR training has been updated to include Learning Disability Awareness. A training programme called Patients are People is established which helps staff to consider the patient experience. The day commences with production from The Twisting Ducks, a Theatre Group of actors who have a learning disability, the session is very effective at demonstrating a patients experience and challenges participants beliefs about disability. Within the Essential Communication Skills Programme, which the Trust delivers, skills to aid communication between a patient with a learning disability, carers and the professional are demonstrated. The Trust has a mandatory Learning Disability Awareness Package as part of the mandatory training within the safeguarding domain. The Trust has establishing learning disability champions across all sites, to raise awareness of patients needs. Learning disability newsletter is available, to raise awareness of developments within the Trust. 12
Does the Trust have protocols in place to encourage representation of people with learning disabilities and their family carers within Trust Boards, local groups and other relevant forums, which seek to incorporate their views and interests in the planning and development of health services? The Trust has an established Learning Disability Steering Group, chaired by Mrs Blackburn, Deputy Director of Nursing and Patient Services; the group also includes a patient representative who has a learning disability and a carer who brings their perspective to the group. The Trust is also a proactive member of established regional forums including the North East and Cumbria Learning Disability Network. The Trust is offering work experience to young people with Learning Disabilities with several young people on placement at present. Current placements include Weight Management, Internal Medicine administration, Loan Equipment Services, Sterile Services, Linen Room. Does the Trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in routine public reports? The Trust elicits patient feedback. The individual issues raised are fed back to relevant staff and services and findings are reported via the Learning Disability Steering Group, Patient Carer and Public Involvement Group and Patient Experience Report on a regular basis and public Trust Board Reports. Challenges and Priorities planned in 2017/18 include: Further development of easy read information for patients with learning disability. To continue to collect patient feedback to inform future developments and share this within the Patient Experience report to achieve greater staff awareness and understanding and wider public dissemination of these findings. Ongoing Audit of utilisation of Hospital passports, needs assessments and care pathways. To continue to raise awareness within Children s Directorate to enable clinical teams to identify children with a learning disability. Completion and Trust endorsement of the hospital passport for children and young people with learning disabilities. Raise awareness within community and hospital Midwifery Services to identify expectant parents with learning disabilities. To ensure information is provided in a format to ensure involvement in informed decisions making around expectant Mum and baby s health needs. Continuation of the mortality review of patients with learning disabilities. 13
Appendix Two Case Study The Patient was a thirteen year old young woman with learning disability, autism, and epilepsy. The Learning Disability Liaison Team received a request for the implementation of reasonable adjustments to facilitate an attendance at hospital for a MRI scan, lumber puncture and bloods under general anaesthetic. At the time of the referral, the young woman was an inpatient on a low secure unit and sectioned under the Mental Health Act (2007) due to her volatile/aggressive behaviour towards herself and others, and required 2:1 staffing at all times. The Learning Disability Liaison Nurse initially co-facilitated a walk through with staff from the secure unit to the ward to which the girl was to be admitted with the ward sister. This identified clear risks given her current behavioural presentation and the inappropriateness of the proposed environment, a very busy day unit, limited environmental space (especially in light of the potential need for restraint), a cubicle could not be guaranteed due to limited availability and priority to be given to those who were clinically ill. Therefore a more spacious ward with availability of a cubicle was sort and identified Once a ward had been identified, there was comprehensive planning through mutidisciplinary meetings (including both internal and external staff to NUTH, members included anaesthetist, psychiatrist, hospital children s matron, ward sisters and consultants, NUTH security staff). The patient would attend with staff that had a good relationship with her, reducing the risk of escalation in her behaviour and the need for restraint. Staffs from the secure unit were trained in restraint practices and their risk assessment and rationale shared with hospital professionals. The patient shows a historical propensity to become agitated and disturbed, to the extent she may become aggressive and assaultive. Although physical intervention will be a last resort and only used when all other avenues of de-escalation have been exhausted without success, its use may be required whilst in attendance at hospital. Staff will support patient if she shows signs of agitation, violence or aggression. If she becomes physically aggressive, there may be a need for supporting staff to use appropriate physical intervention, which may include arm holds, active support to keep her and others safe (all escorting staff are trained accordingly). Escorting staff will take the lead in any physical intervention. Mum is in agreement of this plan and understands the rationale for this. Liaison services at the RVI have been given a copy of this plan to enable them, should the situation arise, to be aware of the steps escorting staff may need to take should the patient escalate her behaviour, becoming aggressive or violent. A clear plan was developed: The Patient would have access to a social story prior to admission to support with any anxieties she may have had visiting hospital. This was co-developed with the Occupational Therapist, Speech and Language Therapist (secure unit) and Learning Disability Liaison Team. The Patient would be woken early and supported with her self-care routine. No food or liquid to be given (anticonvulsant medication to be given). She would leave the secure 14
unit with two members of staff and Mum. Drive to the hospital and park in a prearranged parking space. Proceed to ward environment where, mum would confirm admission information and meet the anaesthetist who will prescribe pre-med. Once sedation had taken effect, patient to be taken via bed/trolley to Neuroradiology Department, accompanied by secure unit staff and Mum. Interventions performed under general anaesthetic i.e. lumber puncture, MRI and bloods. Mum and secure unit staff to remain in Neuroradiology Department to support patient on waking (and to fulfil legal requirement of Section 17 leave of absence under restrictions of her section of the Mental Health Act 2007).Patient, staff and Mum to return to the ward to enable patient to recover, to return back to the secure unit when appropriate. Newcastle Upon Tyne Hospitals staff arranged a cubicle in a quiet area of the ward and allocated an area for staff to wait should the patient need quiet time. Information regarding how the patient took medication and pre-med discussed with anaesthetist, along with cannulation access and consent prior to intervention. The plan above was discussed and agreed by all involved in the admission. Feedback from secure unit staff: A big thanks for your support with this young lady. The day was planned really well and the ward staffs were excellent. We had a robust contingency plan in place, covering all eventualities, although on the day it was not required. Waiting was kept to an absolute minimum, and being the first on the list was an immense help. We arrived at 07:45 and left at 12 Midday, having had all requested tests carried out. In effect, the day went as well as it could have. Please convey our thanks to all of those involved 15