A system-wide independent investigation into concerns and issues raised relating to the safety and quality of CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust (21 March 2023)

Summary

Niche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019.

WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services.

This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review. 

Content

Summary of recommendations

• Recommendation 1 (TEWV): It is clear from the research that patients and their families (and some staff) were ignored and that their concerns and complaints are now found to be, on the whole, justified. The Trust must seek assurance that complaints, concerns and feedback are taken seriously and managed in line with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 particularly in relation to recording receipt of a formal complaint. Additionally, feedback and concerns on a service must be comprehensively reported and reviewed on a frequent basis, and importantly, that feedback is acted upon.
• Recommendation 2 (TEWV): Formal corporate decision-making processes and outcomes were difficult to trace and evidence. The Trust should seek assurance that there is a ratified minute of key organisational decisions.
• Recommendation 3 (TEWV): Action plans relating to West Lane Hospital were not connected to improvement programmes or risk registers. The Trust should ensure that there is strategic oversight of actions through the Board, Committee or working group where multiple interventions are involved. This will ensure that actions are not duplicated with other activities or overlooked. Using a programme approach around improvement plans and risk registers increases the accountability and enforceability around actions.
• Recommendation 4 (TEWV): There were issues with the consistent application of Duty of Candour at the Trust. The Trust should seek assurance that there are now mechanisms in place to assess that the Duty of Candour Policy is effectively implemented. Additionally, where there has been a death in a service, whether through self-harm/suicide or homicide, that families are given appropriate, meaningful, timely and compassionate family liaison and support through personal contact with a nominated officer of the Trust.
• Recommendation 5 (TEWV, CNTW, North East & North Cumbria ICB, Middlesborough Council, NHSE and provider collaborative, and CQC): TEWV, CNTW and System Partners need to seek assurance that they have resolved the problems associated with the clinical transitions phase (between services and child to adult). A compound recommendation is required to address this deficit:
  a) TEWV must provide assurance that a full gap analysis between the 2018 Healthcare Safety Investigation Branch (HSIB) investigation and its own position has been completed. As the Trust still delivers Tier 3 CAMHS services they should expedite a review of processes and procedures in relation to transitions.
  b) CNTW need to expedite a review of processes and procedures in relation to transition of CNTW young person inpatient to adult services.
  c) Patient as well as stakeholder feedback associated with transitions between CAMHS and other services (such as AMHT) should be sought and incorporated into service redesign by all parties.
  d) Effective governance surrounding transitions was not always in place. The good practice relating to transitions which is described within NICE Guidance should be translated into practice and delivered by all parties.
  e) Where a young person is in receipt of T4 care and transferring back to T3, there must be a joint response between health and the relevant local authority children’s services (in this case Middlesborough Council) so that the young person is prepared for life in the community and can be properly supported and their risks appropriately managed.
  f) ICBs, NHSE and provider collaboratives must ensure that providers with a PICU have a written protocol that details the pathway for discharge, including timescales for involving in arrangements, the families and the young person. This will ensure that, wherever possible, a young person is not suddenly transferred without adequate preparation.
• Recommendation 6 (TEWV): There was a gap between the development and successful implementation of important care initiatives (such as least restrictive practice), plans and evidence-based changes to practice. The Trust must seek assurance that there are implementation plans for new initiatives, policies or procedures and that these are evidence-based, being implemented correctly within services and monitored appropriately.
• Recommendation 7: There was a lack of systematisation in relation to the identification, mitigation and actioning of known risks at a ward, service and corporate level. A compound recommendation is required to address this deficit:
  a. TEWV must ensure that risk assessments for young people in CAMHS are based on a psychological formulation and are developed by a multidisciplinary team in conjunction with the young person and their family.
  b. TEWV must ensure that proper training is provided to staff around clinical risk management and how to ensure that action is taken consistently.
  c. TEWV must provide assurance that it meets the requirements of the new Patient Safety Incident Response Framework by 2023.
  d. The North East & North Cumbria Integrated Care Board (ICB), NHSE, and provider collaborative must seek assurance that TEWV has a robust environmental and ligature risk assessment process and the ability to respond effectively and urgently to mitigate risks identified through this process (including risks identified on Tunstall Ward).
  e. North East & North Cumbria Integrated Care Board must assure themselves that CNTW are following the NHS Child and Adolescent Mental Health Services Tier 4 (CAMHS T4): General Adolescent Services including specialist eating disorder service specification and the QNIC standards for use of mobile phones and social media access in inpatient environments.
  f. The application of robust risk assessment forms part of the CQC regulatory framework. The CQC should routinely examine the quality and consistent application of TEWV’s clinical risk assessment, clinical risk training and the relationships to local and corporate risk registers.
• Recommendation 8 (TEWV): The function of Executive team meetings in terms of operational involvement lacked clarity. The Executive team meetings must clearly define and record actions which they are directly responsible for, or, where actions have been delegated. The ET should recognise that it has the mandate to form task and finish groups.
• Recommendation 9: Safeguarding between mental health providers and system partnerships was insufficient to protect young people in West Lane Hospital. Despite the availability of Working Together Guidance, responsibilities and obligations internally and externally between agencies (providers and system colleagues) were confused, interpreted differently by individuals and consequently gaps developed. A compound recommendation is required to address this deficit:
  a. NHS England Specialised Commissioning, the North East & North Cumbria ICB and provider collaborative and the South Tees Safeguarding Children Partnership Board and LADO should now all reflect upon matters raised within this report and determine whether further internal review is required to ensure proper learning occurs within each respective agency. All relevant Safeguarding Children’s partnerships need to ensure that there are sufficient mechanisms in place to prevent a recurrence of the same.
  b. The North East & North Cumbria ICB and provider collaboratives should obtain assurance that provider organisations have sound systems and processes to safeguard young people in mental health facilities, and these provide regular robust assurance to NHS England Specialised Commissioning of effective working.
  c. Middlesbrough Council and Health providers/ key partners must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision to ensure that support is holistic and meets the educational; social; physical health and emotional needs of children and young people as well as their mental health needs.
  d. Local Authorities and Health providers must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high.
  e. Durham County Council must ensure that responses to referrals are completed within expected time frames, and subsequent assessments always incorporate the views of the family and young person.
  f. North East and North Cumbria Integrated Care Board and the Provider Collaborative must consider the impact and risks on Tier 4 CAMHS if a local Safeguarding Board is found to be weak or inadequate, or a local provider is found to have a major staffing issue.
  g. Where Safeguarding concerns are raised about a child, these must include a formal consideration of other vulnerable family members for the lifespan of care.
  h. Middlesbrough Council must respond formally to serious concerns raised about the care and treatment of a young person under their care and explore concerns with the family and the young person.
• Recommendation 10 (TEWV): Reporting structures were disconnected between various tiers of governance, and this prevented the ‘drill-down’ required for effective oversight and effective learning. The Trust must ensure rounded reporting arrangements to support proper Board assurance consisting of both hard evidence and soft intelligence. This should include a ‘trigger tool’ when a ward or department is experiencing ‘stress’, such as failing to complete training, debriefs, high sickness absence, low staff morale and this should be viewed alongside patterns of incidents, harms and complaints.
• Recommendation 11: There were gaps in relation to both the commissioning of effective services and in relation to the regulatory oversight in relation to West Lane Hospital. Assurance seeking activity was weak with a lack of sufficient scrutiny of both hard and soft intelligence. A compound recommendation is required to address this deficit:
  a. NHS England Specialised Commissioning and the Care Quality Commission (CQC) must ensure that when there is enhanced surveillance of services following quality concerns, the themes and patterns of all incidents are rigorously scrutinised and analysed.
  b. NHS England Specialised Commissioning, the provider collaborative and the North East & North Cumbria ICB, should work together with the Directors of Children's Services in the North East region. This is to ensure that services are commissioned which will meet the needs of the growing number of young people with complex needs and challenging behaviours that require integrated health and social care responses.
  c. A demand and capacity review (under the provider collaboratives programme and in association with each local authority) should be undertaken to ensure services have the appropriate capacity locally to minimise placing children out of area and to ensure the availability of suitable specialist care.
  d. TEWV/NHS England, the provider collaborative and Middlesbrough Council must provide assurance that all looked after children specifically with a diagnosis of autism have care provided that is in line with the NICE guidance on autism spectrum disorder in under 19s: support and management, recognising the challenges in the system.
• Recommendation 12: (NHS England) A full assurance review of progress against the recommendations contained within this report must be completed in 6-12  

TEWS response to the report

TEWV-assurance-statement-20-March-2023.pdf