Special review of mental health services at Nottingham Healthcare NHS Foundation Trust: Part 2 (Care Quality Commission, 13 August 2024)

Summary

Following the conviction of Valdo Calocane in January 2024 for the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber, the Secretary of State for Health and Social Care commissioned the Care Quality Commission (CQC) to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) under section 48 of the Health and Social Care Act 2008.

The first part of this review, published in March 2024, set out the CQC’s findings of their assessment of patient safety and quality of care provide by NHFT, and progress made at Rampton Hospital since their last inspection in July 2023. This second report provides a rapid review of available evidence related to the care of Valdo Calocane.

Content

Throughout the 2 years he was under the care of Nottinghamshire Healthcare NHS Foundation Trust (NHFT), the CQC states that it is clear from Valdo Calocane (VC’s) records that he was acutely unwell. VC showed symptoms of psychosis, including presenting as guarded, and having little understanding or acceptance of his condition throughout his care under NHFT. Problems with him not taking his medicine were also recorded from early on.

Their review found:

• If the decision had been made to treat VC under section 3 of the Mental Health Act (MHA) 1983, during his fourth admission to hospital, further options would have been available for his care and treatment in the community
• There was a series of errors, omissions and misjudgements, all of which were compounded by the symptoms of VC’s illness.

A core part of the CQC's review was to consider whether the evidence we gathered from VC’s care records indicated wider patient safety concerns or systemic issues in Nottingham. The CQC noted that while they did not find any widespread patterns with 10 other cases that we reviewed as a benchmark, many of the issues we have identified are consistent with the problems we found in our wider review of the quality of care and safety of services at NHFT.

Recommendations

The CQC recommended that NHFT must:

• Review treatment plans on a regular basis to ensure that treatment prescribed is in line with national guidelines, including from NICE (National Institute for Health and Care Excellence), specifically when it relates to treatment of schizophrenia and medicines optimisation.
• Ensure clinical supervision of decisions to detain people under section 2 or section 3 the Mental Health Act (MHA) 1983 and regularly carry out audits of records for people detained under these sections, which are reported to the NHFT board.
• Ensure that regular auditing of medicines monitoring takes place within community mental health teams to identify any themes, trends and required learning.
• Ensure that, in line with national guidance and best practice, staff are aware of the importance of involving and engaging patients’ families and carers and that they do so in all aspects of care and treatment, including at the point of discharge, with patient consent. The trust should ensure that where patients do not give consent, this is reviewed on a regular basis in line with best practice and on all the available information available to the multidisciplinary team.
• Have a robust policy and processes for discharge that consider the circumstances surrounding discharge and whether discharge is appropriate.

For community mental health services for working age adults, the CQC recommended that NHFT must:

• Ensure regular medicines monitoring takes place within the community and address any issues quickly where problems are identified.
• Ensure all practicable efforts are made to engage patients who have disengaged from the early intervention in psychosis service. This includes referring people who find it difficult to engage with services to a team that provides assertive and intensive support.
• Ensure there is a standard operating procedure in place for early intervention in psychosis and community teams to follow when a patient does not attend for appointments and follow-up actions are defined for care co-ordinators.

The CQC also recommended that NHS England:

• Appoints a named individual to take ownership for the delivery of these recommendations.
• Ensures that providers’ boards fully understand their role in the oversight of the needs of patients who have a serious mental illness and who find it difficult to engage with services. This includes developing local services in partnership with others to provide intensive support in order to prevent this cohort of patients from falling through the gaps.
• Ensures every provider and commissioner in England undertakes a review of the model of care in place for patients with complex psychosis who typical services struggle to engage and who present with high risk.
• Within the next 12 months, provides evidence-based guidance setting out the national standards for high-quality, safe care for people with complex psychosis and paranoid schizophrenia.
• Within 3 months of the publication of the national standards for high-quality, safe care for people with complex psychosis and paranoid schizophrenia, ensures every provider and commissioner develops and delivers an action plan to achieve these.
• Through the providers’ boards, ensures delivery of the actions within 12 months of the standards being published.
• (Together with the Royal College of Psychiatrists: reviews and strengthens the guidance to clinicians relating to medicines management in a community setting and reviews how legislation is used in the community to deliver medication for those patients who have a serious mental illness and where it is known they are non-compliant with medication regimes.