‘Claire’ received support for her mental health needs over a significant number of years from a number of different healthcare providers, including our Trust, Northamptonshire Healthcare NHS Foundation Trust (NHFT). The Coroner identified that Claire died as a result of natural causes and it was acknowledged that no organisation was directly responsible for Claire’s death. However, whilst we were not responsible for her death we take our responsibility for our patients, carers and our standards of care very seriously and are robust in any attempts to improve.
We immediately completed a thorough investigation into Claire’s treatment and worked closely with her family and involved other agencies to understand what happened. The Coroner had a number of improvement actions at inquest for all involved agencies; we are confident that we have identified and addressed these as part of our own investigations.
As a result of our investigations in 2014/5, we have identified and taken action to improve our services, processes, staff training, and handover procedures. Our priority and investigations have been focussed on understanding Claire’s experience from her point of view and her journey through all agencies. We have been thorough and robust in the actions we have taken as a result of our investigation.
These actions include:
- A transformation of our mental community teams, with a much closer relationship between crisis and other services. A detailed and robust change and improvement in ward structures led by service users and carers needs
- Building on our successful acute hospital liaison service in place in both KGH and NGH. Improvements to the handover processes between all hospitals to address the specific concerns raised by the coroner regarding communication between Trusts
- Training for all mental health ward based staff in physical health care skills
- We have appointed physical health nurses across all the adult wards in Berrywood
- Service users and carers co-producing a range of service improvements in both wards and community teams based on a recovery focus.
During their most recent inspection of our Trust in 2017, the CQC recognised our improvements in the provision of care; that we have a robust system to audit the quality of our care; that we have a good overview of any challenges we may face as an NHS provider; and that we have strong capacity and ability to recognise and address these.
During the Coroner’s inquest in January 2016, the Serious Incident report we produced following our own internal investigation was described as robust and thorough by the independent expert consultant psychiatrist at the inquest. The Coroner was reassured by the measures we have taken to remedy any shortcomings identified and recognised the specific measures to employ physical health nurses.
We welcome any further recommendations within the Safeguarding adult’s board review and we will offer continued assurance on the points raised. We are satisfied that the ongoing work to improve crisis care and provide quality outcomes for patients will address these wider points.
Angela Hillery, Chief Executive of NHFT, said: “Throughout our original investigation we worked closely with Claire’s family to develop the incident report and subsequent action plan. As a Trust, we would like to take this opportunity to again offer our deepest condolences to Claire’s family.”
Dr Alex O’Neill-Kerr, Medical Director, NHFT, said: “We are confident that our actions in investigating the care Claire received at NHFT has been thorough and has focussed on learning what is best for those we care for and then making improvements. We are committed to working with other agencies to continually make improvements in how we work together. As an example, NHFT delivers a round-the-clock acute psychiatric liaison service within the emergency department of both general hospitals . This was highlighted as an area of outstanding practice in a recent inspection of Northampton General by the Care Quality Commission.
“Further to this, in early 2017 the CQC conducted a comprehensive inspection of our services and rated us as GOOD overall and OUTSTANDING for care. On the independent patient review website iWantGreatCare, Berrywood Hospital has an average rating of 4.5 out of 5 from over 2,900 reviews. This is recognition of the unprecedented amount of work we have undertaken since 2014 to continue improving our standards of care, and we continue to work with our partners, patients and carers across the county to make further improvements where needed.”