Summary of Findings and Recommendations from the Independent Review of Tees, Esk and Wear Valley’s NHS Foundation Trust

Introduction

The following provides a summary of the findings and recommendations identified by an independent review of the Tees, Esk and Wear Valley’s NHS Foundation Trust, in relation to the deaths of three teenage girls who were within the service over a period of time.

In November 2022 an independent investigation report was released in relation to these cases and from these 120 failings in care were identified throughout the three cases. In March 2023, a subsequent report was released in relation to “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 Valley’s NHS Foundation Trust.”

In this article, we highlight some of the governance issues identified in the system-wide investigation and share some of the key recommendations provided across the three investigations that should be considered by all mental health services.   

Governance Issues identified within Tees, Esk and Wear Valley’s NHS Foundation Trust

In March 2023, the independent review published a system wide independent investigation report of the CAMHS provision Tees, Esk and Wear Valley’s NHS Foundation Trust. Below are details of some of the governance issues identified as part of the review. These issues included:

• Ineffective escalation mechanisms and fundamental weaknesses in the organizational governance resulted in a failure of corporate oversight of the quality and safety of the service provided.
• The function of senior teams in terms of operational involvement lacked clarity.
• Reporting structures were disconnected between various tiers of governance, and this prevented the ‘drill-down’ required for effective oversight and effective learning. 
• Action plans relating to West Lane Hospital were not connected to improvement programmes or risk registers. 
• Significant issues identified in the application of the Duty of Candour at the Trust.
• 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. 

Key Recommendations from the Investigation

Below we have summarised some of the key system-related recommendations identified in the independent review.

Governance

• Implement a full review of the organizational structure and decision-making processes including the role and responsibilities of Teams in terms of operational involvement.
• Implement effective reporting arrangements to support proper Board assurance. This should include a mechanism to identify when a 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.
• Ensure that the Duty of Candour Policy is effectively implemented. Where there has been a death in a service, that families are given appropriate, meaningful, timely and compassionate support through personal contact.

Incident Management

• Ensure there is much greater detail and understanding of the patterns and instances of harm within services through the regular reporting and interrogation of data, when required, to inform both individual patient clinical care planning and service understanding of safety and quality issues.
• Response to incidents must reflect robust clinical governance and conformation with the NHS Serious Incident framework – including the utilization of external review where deemed appropriate.

Risk Management

• Implement a system for the identification, mitigation and actioning of known risks at a ward, service and corporate level.
• Implement a robust environmental and ligature risk assessment process and the ability to respond effectively and urgently to mitigate risks identified through this process.
• Ensure that any person with a recent history of self-ligature has a written care plan that identifies how staff are to care for the person and mitigate the risks of fatal self-ligature.
• Risk assessments for people are developed by a multidisciplinary team in conjunction with the person and their family, as applicable.

Complaint Management

• The service must respond formally to concerns raised about the care and treatment of a person under their care and explore concerns with the person and/or their family.
• Improve the response to complaints, so that complaints are managed in line with best practice guidance.

Care Plans and Restraint

• Care Plans incorporate evidence-based practice.
• Care Plans are written so that they are clear, patient-centred, easy to understand and follow
• The management of restrictive interventions must be part of an agreed philosophy and approach, with clear protocols embedded to guide practice.
• Where there is a risk of retraumatising people in restraint, the triggers for trauma are recognised and there are written plans of care to manage this risk.

How can HCI help?

At HCI, we help providers of health and social care make intelligence driven decisions to attain, manage and improve quality, safety and regulatory compliance. We work with Mental Health Services to support the development of comprehensive Quality and Safety Management Systems that encompass many of the key system areas identified in this review such as Governance Structures, risk management, audits, incident management and complaint management.

HCI also work with mental health services to conduct independent serious incident reviews, including complaint investigations, systems analysis and look back reviews. We offer a structured review process which is developed and implemented with a service user / patient focus, working to identify the system issues that may exist and identify the actions required to drive a culture of safety within the organisation.

For more information contact HCI at 01 629 2559 or info@hci.care.