MENTAL HEALTH ACT MONITORING COMMITTEE Thursday 15 June 2017
Taff Meeting Room, Cwm Taf University Health Board,
Ynysmeurig House, Abercynon 2.00pm
AGENDA
Lead / Attachment
PART 1 - PRELIMINARY MATTERS
1.1
Welcome and Introductions
Chair / Oral
1.2 Apologies for Absence
Chair / Oral
1.3
Declarations of Interests Chair / Oral
1.4 Unconfirmed Minutes of the meeting of the Mental Health Act Monitoring Committee held on 16 February
2017
Chair
Attachment
1.5 Matters Arising
Chair / Oral
1.6 Action Log Chair
Attachment
1.7 Chairs Report
Chair
Oral
PART 2 - ITEMS FOR DISCUSSION
2.1 Annual Report on Suicides
Clinical Director MH
Attachment
2.2
Mental Health Act Monitoring Committee Annual Report
and Committee Self Assessment Questionnaire
Board Secretary
Attachment
PART 3 - GOVERNANCE, PERFORMANCE AND ASSURANCE
3.1 Mental Health Act – Quarterly Activity Statistical Report Director of Primary,
Community & Mental Health
Attachment
3.2 Mental Health Crisis Care Concordat
South Wales Police
Attachment
3.3
Mental Health Act Breaches / Analysis of Unlawful
Detention
Assistant Director of
Operations MH
Attachment
Agenda
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3.4
3.5
Risks related to the Monitoring of the Mental Health Act
National Benchmarking data on Breaches
Assistant Director of
Operations MH
Oral
Ian Wile (C&V UHB)
Attachment
PART 4 – FOR INFORMATION
(These items will only be discussed if related issues are raised with the Chair in advance of the meeting)
4.1 Internal Audit Report on Mental Health Act S117 for
review and monitoring from Audit Committee 3 April 2017
Board Secretary
Attachment
4.2 Internal Audit Report - Royal College of Psychiatrists
Review Follow up
Board Secretary
Attachment
PART 5– OTHER MATTERS
5.1 To review the Forward Look for 2017/18
Chair
Attachment
5.2
Any other urgent business
Chair / Oral
5.3 Date of Next Meeting
Thursday 14 September 2017 2.00pm
Ynysmeurig House, Navigation Park, Abercynon
Agenda
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Agenda item 1.4
Unconfirmed Minutes of the Mental Health Act Monitoring
Committee meeting held on 16 February 2017
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Mental Health Act Monitoring Committee Meeting
Minutes of the meeting held on 16 February 2017
Cwm Taf UHB, Abercynon Present
Prof Donna Mead (Chair) Vice Chair of the University Health Board Mr Mel Jehu
Mr John Palmer
Independent Board Member
Director of Primary, Community & Mental Health
Dr Paul Davies (PhD) Mr Peter Thomas
DI Karen John Mr Mark Anderton
Assistant Director of Operations (ADO) South Wales Police
South Wales Police Merthyr Tydfil County Borough Council
Ms Gail Hollowman
Ms Samantha Shore
Mr Peter Halford Dr Adarsh Shetty
Rhondda Cynon Taf County Borough Council
Senior Nurse, Adult Mental Health
Consultant Psychiatrist, CAMHS Clinical Director, Mental Health (in part)
In attendance
Miss Gwenan Roberts Miss Kate Bowd
Mr Phil Robson
Head of Corporate Services Secretariat
Vice Chair, Aneurin Bevan UHB
MHAM/17/01 WELCOME AND INTRODUCTIONS
The Chair welcomed everyone to the meeting of the Mental
Health Act Monitoring Committee and Members were invited to introduce themselves.
Mr Phil Robson was in attendance from Aneurin Bevan University Health Board to observe.
MHAM/17/02
APOLOGIES FOR ABSENCE
Apologies for absence were received from Dr Tracy Gardiner; Ms Julie Cude; Mr Phil Lewis; Mrs Pamela Connor; Mr Gregory Lloyd;
and Supt. Jim Dyson.
MHAM/17/03 DECLARATIONS OF INTEREST
There were no additional declarations of interest.
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MHAM/17/04 MINUTES OF THE PREVIOUS MEETING
The minutes of meeting held on the 8 December 2016 were
recorded as a true and accurate record subject to the following addition:
On page 2 – Apology to be recorded for Samantha Shore.
The Chair thanked Mr Mel Jehu for chairing the last meeting.
MHAM/17/05 MATTERS ARISING
MHMAC/16/62 – Mental Health Act Breaches - Category 4 breaches was on the agenda for discussion.
MHAMC/16/65 – Her Majesty’s Inspectorate of Constabulary - Unannounced Inspection (HMIC) – Members NOTED the
partnership data.
MHAM/17/06
ACTION LOG
Members RECEIVED a copy of the action log and AGREED the
following:
1. MHAM/16/44 - Due to Supt Jim Dyson being unable to attend the meeting, this item would be received at the next meeting.
2. MHAM/16/46 – Benchmarking statistical report data – an update would be provided at the meeting.
3. MHAM/16/54 – Completed 4. MHAM/16/61 – Mental Health Crisis Concordat – update report
from SWP was on the agenda. 5. MHAM/16/62 – MHA Breaches – Draft proposal was on agenda
for information. Members were assured that work was in progress and NOTED that the proposal was currently at the
consultation phase which had been shared with operational leads of Health Boards for comment. Members NOTED that a
pilot was underway in Cardiff and Vale UHB and dependent on
the success would be rolled out in June. Members NOTED that it had been formally agreed to review at individual health
board Mental Health Act Monitoring Committee meetings. 6. MHAM/16/65 – No response had yet been received from South
Wales Police. It was AGREED that this would be discussed with Supt Dyson at the next meeting.
(Dr A Shetty joined the meeting).
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GOVERNANCE, PERFORMANCE AND ASSURANCE
MHAM/17/07 MENTAL HEALTH ACT – QUARTERLY STATISTICAL REPORT
Mr J Palmer presented the Mental Health Act Monitoring Report
for Quarter 3, Members NOTED that the report was evolving to ensure the latest information available and the following key
areas were highlighted: The report contained the reconciled data and had been
validated by the Health Board and South Wales Police. Quarterly reports would be provided to the Committee to
review any variations and to identify any mitigation used in practice.
Inpatient MHA – Members NOTED the decrease within the data of the sub sections as within normal variation
Members AGREED that the trends would be illustrated in a bar chart for ease of reference in the next report.
Tribunals had slightly decreased. The number of patients held using Section 136 had slightly
increased. The information was felt to be consistent and there were no issues for particular discussion. Members
NOTED that page 9 showed the increased numbers of
patients detained under Section 136 were as expected during the winter period.
Deaths while detained – Members NOTED a small increase from previous data
Staff Training – Members AGREED to receive an update on annual staff training in the next report; courses undertaken
to date and the costs associated. Dr P Davies advised that adult detention placements were
based on specialised nature of treatment and not commissioned and provided by the Health Board.
Mental Health Advocates – Mental Health activity for Q2/Q3 indicated that services were working effectively. Dr P
Davies (PhD) advised that the service provided was a non professional advocacy; independent advocates were
working in partnership to act on behalf of the patient (as
the voice of the patient). Dr Shetty advised members that there was also an Older Persons Advocacy service within
the Mental Health services. Dr P Davies (PhD) advised that Ms L Garwood (Clinical Director) would provide an update
to the Mental Health Partnership Board on the advocacy service.
Code of Practice - Members NOTED that hospital managers were aware of the new Code of Practice. Dr Shetty
confirmed that the Health Board was compliant.
Members of the Committee RESOLVED to: DISCUSS and NOTE the report.
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MHAM/17/08 MENTAL HEALTH CRISIS CONCORDAT
The first written report was received from South Wales Police and was presented by Mr Peter Thomas. The report provided an
update on the progress to date within the South Wales Police
service and provided a précis on the key issues for the Force as a result of the HMIC Unannounced Inspection.
Mr Thomas confirmed that a meeting had taken place on 16
January 2017 with Dr Gaynor Jones as the new Chair and supported by Mr James Thomas at the Caswell Clinic. The Mental
Health Care Concordat was discussed and it had been decided to write to the Health Boards and Local Authorities, as well as to the
Welsh Ambulance Services NHS Trust, the Child and Adolescent Mental Health network service and to MIND to work together to
implement a Crisis Care Forum. Members NOTED that a Task & Finish Group (T&F) had been established to cover key areas of
the business to implement the plan.
The key areas of business were identified as:
Adverse incident reporting – Members NOTED the aim
to link the Health Boards / Local Authorities to improve services.
Training – a training guide had been developed. Members
NOTED that a multiagency steering group had been established and updates would be reported to the T&F
Group bimonthly. A community psychiatric nurse had also been appointed to work in the police control room to offer
advice which was based on work in other force areas which had been supportive to front line staff.
Transport – Members NOTED that the ambulance usage
was low.
Alternative place of safety – Members NOTED that
intervention research was underway to review options between agencies. However, there was an impasse as
additional resourcing issues had been identified. Work was underway in Gwent and a small pilot had been commenced
with a report available of what would be shared. Mr P Thomas explained that costs would be shared and it was
AGREED to discuss with the team from Aneurin Bevan University Health Board regarding progress and potential
invitation to a future meeting. Members NOTED that Cardiff and the Vale UHB had identified a need for a
sanctuary house and were progressing funding options.
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Dr P Davies (PhD) confirmed that there had been several requests using the Freedom of Information Act and press
enquiries in relation to restrictive physical intervention; Members NOTED that extra training had been provided for staff in adult
mental health and there was a plan for robust audits to take
place when restrictive physical intervention had taken place.
Members NOTED that the Police and Crime Act would take effect from May. Dr E Stephenson (Consultant A&E at Prince Charles
Hospital) was working with Cardiff and Vale UHB on the area business restraint to comply with the Mental Health Act Codes of
Practice. Mr P Thomas confirmed that the Welsh Government had established a working group with the Chief Constable to progress
the work. Members NOTED that a National Project Board had also been established to oversee the work. Mr J Palmer AGREED
to draft a letter to the Welsh Government to clarify the position.
Mr Mel Jehu welcomed the inclusion of the Memorandum of Understanding (MOU) and Mr P Thomas explained that the police
would not be called to attend for restraint purposes; Members NOTED that the next phase would be to monitor the compliance
and provide evidence. Mr J Palmer advised Members that he
would ensure that the Health Board was compliant with the MOU and would ensure that the correct sign off and governance would
take place and an oral update provided at the next meeting.
Members RESOLVED to: Thank Mr P Thomas for the report
Receive additional information on the HMIC Inspection report. MHAM/17/09 MENTAL HEALTH ACT BREACHES / ANALYSIS OF
UNLAWFUL DETENTION
Mr J Palmer presented the report and gave an overview of the
key issues.
Mr Palmer explained that work was continuing within the service
to reduce the number of breaches of the Mental Health Act in the Category 1 & 2 sections; Members also NOTED that the Datix
Risk Management system was now in use to report all breaches in line with patient safety issues.
Members NOTED the 4 breaches on recording personal
information and that the numbers were low against the benchmarked data available; specific training was in place for
staff to prevent further avoidable breaches of the Act. Two incidents were also reported which had the incorrect addresses
which would have resulted in breaches of the Act if they had not been amended within 14 days.
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Dr A Shetty provided an update on the consent to treatment; Dr
Shetty confirmed that Ms P Wilson had appropriately escalated the issue and had provided feedback to the Consultant. Dr Shetty
explained to the Committee that the care provided to patients
was not adversely affected in terms of the application of the Mental Health Act including administrative errors and advised the
Committee that the model of care was being revised to ensure compliance.
Members discussed exploring ways of better sharing information
prior to the Committee meeting as this report was a ‘closed’ report as it included personal identifiable information in relation
to breaches of the Mental Health Act. Mr J Palmer agreed to seek a different approach to sharing data / information to the
Committee which could be via the secure portal. Further information would be shared prior to the next meeting.
Members RESOLVED to:
NOTE the report.
MHAM/17/10 RISKS RELATED TO THE MONITORING OF THE MENTAL
HEALTH ACT
No risks were identified.
FOR INFORMATION
MHAM/17/11 ADULT MENTAL HEALTH PERFORMANCE REPORT
Mr J Palmer provided an update regarding the improved performance related to the Mental Health Measure and explained
that it was expected that all targets would be met by the end of March 2017. Members were advised that there had been a
significant improvement in the assessment, treatment and care planning. Members NOTED that the Finance, Performance &
Workforce Committee had undertaken a deep dive into the
performance and were assured; ongoing performance would also be scrutinised by that Committee and quarterly updates would be
received at the Mental Health Act Monitoring Committee for information only.
Member RECEIVED and NOTED the report.
MHAM/17/12 CHILD AND ADOLESCENT MENTAL HEALTH PERFORMANCE
REPORT
Mr J Palmer provided an update regarding the performance within the CAMH Services. Members were advised that there had
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been significant improvement over the year and the Health Board was on target to deliver the planned year end position.
Member RECEIVED and NOTED the report.
MHAM/17/13 NATIONAL APPROACH TO MENTAL HEALTH ACT BREACHES
REPORT
Mr J Palmer gave an overview regarding the national approach to
Mental Health Act breaches. The proposal has been adopted by other Health Boards and Mr Ian Wile (C&V UHB) had been invited
to attend the next meeting to provide an update. The Chair invited any further comments be sent to Ms P Connor for
collation and onward inclusion in the national report.
Member RECEIVED and NOTED the report.
OTHER MATTERS
MHAM/17/14 TO REVIEW THE FORWARD LOOK FOR 2016/17
Members RECEIVED and NOTED the Forward Look Plan.
It was AGREED to add:
Receive an update from South Wales Police on the HMIC inspection report
The Committee Annual Report Update on Suicide (Annual Report)
National Approach to Breaches – Ian Wile to attend next meeting
Discuss the pilot on alternative place of safety with the team at Aneurin Bevan UHB.
MHAM/17/15 ANY OTHER URGENT BUSINESS
None
MHAM/17/16 DATE OF NEXT MEETING
The next meeting would take place on Thursday 15 June 2017 at 2.00pm at Cwm Taf UHB, Headquarters, Ynysmeurig House,
Abercynon.
Signed ……………………………………………….
Prof Donna Mead (CHAIR)
Date …………………………………………………..
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Agenda item 1.6
Action log Page 1 of 1
Mental Health Act Monitoring Committee
15 June 2017
MENTAL HEALTH MONITORING COMMITTEE ACTION LOG
Date Issue Lead Complete / Ongoing
22 June 2016
MHAM/16/44 Ongoing issue regarding very intoxicated individuals to be discussed at the Community
Safety Partnership meeting (June and September
meeting)
South Wales Police Supt Jim Dyson
Ongoing matter – for update 16 February
2017(now June 2017)
8 December 2016
MHAM/16/62 Invite Ian Wile to present the national approach for
benchmarking MHA breaches
John Palmer Update at June meeting
– Ian Wile attending
MHAM/16/65 &
MHAM 17/08
HMIC unannounced inspection – response from
South Wales Police to the chair of the committee to
confirm compliance with the speed of referrals to Mental Health
Supt Jim Dyson To be confirmed
16 February 2017
MHAM/17/07 Mental Health Act – Quarterly Statistical Report Trends to be demonstrated using bar char
Provide enhanced information on staff training including the numbers trained and the amount
of funding used to date
John Palmer June meeting
MHAM/17/08 Discuss the alternative place of safety pilot with Aneurin Bevan UHB and potentially invite to a
future meeting
John Palmer To be confirmed
1.6 Action log
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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AGENDA ITEM 2.1
15 June 2017
Mental Health Act Monitoring Committee Report
6 YEAR ANALYSIS UPDATE OF REPORTED SUICIDE IN CWM TAF
REGION: APRIL 2010 – MARCH 2016
Executive Lead: Mr John Palmer, Director of Primary Care, Community and Mental Health
Author: Dr Paul D Davies (PhD), Mr James McMahon
Contact Details for further information: Paul D Davies RGH 3700 /
Purpose of the Mental Health Act Monitoring Committee Report
The purpose of this brief report is to follow previously detailed reports on
the prevalence of suicide in the Cwm Taf region
Governance
Link to Health Board Strategic
Objective(s)
The Board’s overarching role is to ensure its Strategy outlined within ‘Cwm Taf Cares’ 3 Year Integrated
Medium Term Plan 2015-2018 and the related organisational objectives aligned with the Institute of
Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:
To improve quality, safety and patient experience
To protect and improve population health To ensure that the services provided are
accessible and sustainable into the future To provide strong governance and assurance
To ensure good value based care and treatment for our patients in line with the resources made
available to the Health Board.
This report focuses mainly on supporting all of the strategic objectives
Supporting evidence
National Confidential Inquiry (NCI) on Suicide and Homicide for people with mental illness
Engagement – Who has been involved in this work?
The mental health clinical and management team
2.1 Annual Report on Suicides
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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Mental Health Act Monitoring Committee Resolution (insert √) To;
APPROVE ENDORSE DISCUSS √ NOTE √
Recommendation The Mental Health Act Monitoring Committee is
asked to: DISCUSS the higher levels of suicide in the Cwm
Taf region and the actions aimed at reduction
Summarise the Impact of the Mental Health Act Monitoring
Committee Report
Equality and diversity
Potential equality issues relate to access to services and gender differences
Legal implications All suicides and suspected suicides are reviewed at a Coroner’s hearing
Population Health The socio-economic factors of the Cwm Taf region
impact negatively upon the mental health of the population. High unemployment rates are linked to a
higher suicide rate.
Quality, Safety &
Patient Experience
This analysis acts as a quality assurance check on
how the community is responding to suicide rates and scrutiny of such data will reveal areas for
improvement and action.
Resources None highlighted at present. The improvements recently introduced in Primary Care Mental Health
services over time will make a positive difference as people receive earlier assessment and intervention.
Risks and Assurance
Key risks: Increased suicide rates compared to national
benchmark
Increasing gender differences Increase in middle-aged men
Fluctuating increase in patient suicide above the national benchmark
Health and Care Standards
The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:
Staying Healthy; Safe Care; Effective Care; Dignified Care; Timely Care; Individual Care; Staff &
Resources
http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework_2015
_E1.pdf
Workforce Increasing awareness and skills across a range of
services within health and in other agencies
Freedom of information
status
Open
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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6 YEAR ANALYSIS UPDATE OF REPORTED SUICIDE IN CWM TAF
REGION: APRIL 2010 – MARCH 2016
1. SITUATION / PURPOSE OF REPORT
The purpose of this report is to provide a sixth year analysis and benchmark of
suicide rates in the Cwm Taf Region. The original intention of these reports was to examine trends in years, not months, as suicide rate does not follow a
natural epidemiological pattern.
This report is presented against a background where Cwm Taf region is one of
the most prevalent areas of socio-economic deprivation, substance misuse and mental health problems in Wales.
Through a 5-year strategic framework Cwm Taf UHB (2011 – 2016) has
redesigned mental health services to provide enhanced community care, responsive primary care and effective hospital care and treatment. There have
also been two significant developments through extra funding in the last three years:
The Valleys Steps initiative; a self-referral programme providing intervention and training for people with emotional disorders
The Primary Care Mental Health Service to deliver part 1 of the Mental Health (Wales) Measure
Whilst our strategy and new funding will respond appropriately to the increasing
demand upon primary, secondary and tertiary services there also needs to be
consideration to the wider community response to reducing suicide rates. Previous reports have been presented to Local Service Boards by the Assistant
Director of Operations for Mental Health to discuss the wider response.
A comprehensive clinical governance report focusing on the clinical review of unexpected death in adult mental health was received by the Health Board in
2013, reporting on individual cases known to health services.
2. BACKGROUND / INTRODUCTION
Since 2010 – 11, the Adult Mental Health Directorate has collated local data on the rates of suicide in the Cwm Taf region from the National Confidential
Inquiry (NCI) on Suicide and Homicide by people with mental illness. This report to the Health Board references large sections of the recent Annual Report
in October 2016 1.
Information on all general population suicides (i.e. deaths by intentional self-
harm and deaths from undetermined intent) by individuals aged 10 and over is collected from the Office for National Statistics (ONS). To identify patients (i.e.
1 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2016) Making Mental
Health Care Safe: Annual Report 2016. Manchester: University of Manchester
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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individuals who died by suicide within 12 months of mental health service contact) national data are submitted to mental health services in each
individual’s district of residence or district of death and adjacent districts. Detailed clinical data are obtained for these individuals via a questionnaire sent
to the consultant psychiatrist.
This report is based on findings reported for the local authority regions of
Rhondda Cynon Taf and Merthyr Tydfil which includes all suicide and open verdicts. This report also included data on deaths within the Cwm Taf region of
people non-resident to the area.
3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
The National Confidential Inquiry (NCI) helpfully produce a national report to
benchmark regions in the United Kingdom every year and there is a focus in Wales within the report.
In October 2016, the NCI produced a report examining the 10 year period
between 2004 and 2014.
For Wales the headlines were: There was a drop in suicide rate from 2012 in males and the overall
numbers Cwm Taf region remains the highest rate in Wales at 13.7 deaths per
100,000 population over 2012 -2014. This rate was 13.6 deaths in 2012
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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Compared to the specific rates for other countries, Wales is 11.1 deaths per 100,000 population. Scotland is 14.6 and Northern Ireland 18.0.
2.1 Annual Report on Suicides
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6 Year analysis update of reported suicide in Cwm Taf
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For Crisis Resolution Home Treatment teams (CRHT) in Wales the NCI report that there was an average 5 deaths per year. There was also an overall
increase in the number of suicides under CRHT teams with a rise in 2009 and a substantial fall in 2011.
17 (33%) who committed suicide while under the care of a CRHT died within 3 months of hospital discharge, the majority (11, 65%) within 2
weeks. Eight (14%) had been non-compliant with drug treatment in the month
before suicide and 23 (41%) patients lived alone. There was concern that the rise in suicides of patients under the care of
CRHT between 2008 -2010 was due to premature discharge and paralleled a reduction in inpatient suicides but this has not proved to be
the case over time. More research is required in this area.
Patient suicide: number under Welsh crisis resolution home treatment services
In relation to substance misuse in Wales between 2002 and 2011, the overall
number of patient suicides with a history of alcohol or drug misuse did not change, although numbers have increased since 2008 and the NCI estimate
further rises in 2012.
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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Patient suicide: number with a history of alcohol or drug misuse in Wales (2002-12)
For Wales, and the United Kingdom in general the suicide rate peaks in the
middle-age group as below.
In relation to Cwm Taf we have obtained local data from the NCI over the
last 6 years and report these statistics based upon the date of the actual incident as below. Our aim is to develop a rolling statistical analysis to present
to the Health Board annually because the last year of reporting is always subject to review. This is due to some outcomes not received by the NCI in
time for the annual report and for the reasons reported at the introduction
regarding the epidemiological pattern for suicide.
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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Suicide and open verdict rates for Cwm Taf region from 2010/11 to 2015/16 2 3
Suicide rates by gender for Cwm Taf region from 2010/11 to 2015/16
2 Source: NCI University of Manchester: requested by P D Davies
3 For general population figures, NCI only have complete data on deaths registered (rather than by date of
death) up until the end of June 2016. For patient figures, there may still be unconfirmed cases for the most recent years. Therefore, these figures may change at a later date.
0
5
10
15
20
25
30
35
40
45
2010 2011 2012 2013 2014 2015
Male
Female
All
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6 Year analysis update of reported suicide in Cwm Taf
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% Total in Contact with services for Cwm Taf region from 2010/11 to 2015/16
Recent male suicides have dropped significantly to 16 in 2014/15 and this has been sustained in 2015/16 although at this stage that may be reviewed as
outcomes of Coroners hearings and checks are made by the NCI. However, on the face of it, there is a significant drop in suicide of men which was previously
demonstrating a worrying trend upwards.
Open verdicts have been reported as nil for 2012-2013; a significant reduction on previous years. However this has now risen to 7 for 2014/15 and 5 for
2015/16.
In relation to the percentage of patient suicides in contact with services, there
has been a reduction in Cwm Taf from 29% in 2010/11 to 19% in 2015/16. This latest % is now 5 percentile points below the 10 year average for Wales as
reported below by the NCI between 2002 and 2012.
Region Year % of patient suicides
Wales 2002-12 24 England 2002-12 28
N. Ireland 2002-12 28 Scotland 2002-12 30
As with suicide rate, this statistic has to be viewed over longer periods of time
as the variance can be large between years. Small changes in the total number
in absolute terms in Cwm Taf will have a disproportionate effect on our percentage rates due to our relatively small total population compared to other
UHBs.
0
5
10
15
20
25
30
35
40
2010 2011 2012 2013 2014 2015
% in contact with services
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Within Cwm Taf our strategies on reducing suicide and self harm has been focused on two areas:
1) Children and Young People
Work to reduce suicide and self harm among Children and Young People up to 25 years of age which is over seen by the ‘Reduction in Suicide and Self Harm
in Children and Young People Steering Group’.
This multi agency and multi disciplinary steering group was established in 2009 following the launch of the first all Wales suicide and self harm reduction
strategy ‘Talk to Me’. The steering group identified local priorities and established a number of sub groups to address the key issues (see below).
Structure
Reduction of Suicide and Self Harm in Young People Steering Group
Management of Self Harm
Training Delivery Group
Information / Data Collection
Immediate Response Group
(IRG) Protocol
Cwm Taf Safeguarding
Children Board
Safeguarding Training Delivery
Group
The development of the Immediate Response Protocol to deal effectively with local suicides and attempted suicides among young people and the
impact on families, friends etc. as well capturing lessons learnt has been nationally recognised as good practice.
The training group has also developed a package of training for all staff working with children and young people and this training has now been
delivered to over 800 workers from across all statutory agencies and voluntary sector organisations within Cwm Taf.
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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Training
Level 2 Attendees (2012 – 2015) (826)
2) Adults
Within the Mental Health Directorate the following is provided to reduce suicide among those people our service comes into contact with:
An open access Crisis Resolution Home Treatment service which is open
to self referrals – this is not the standard approach across Wales but we have always felt it important to ensure timely access for people who feel
desperate and may be suicidal The crisis practitioners provide an assessment service into A&E for people
who present with deliberate self harm and offer follow up and signposting as appropriate for people in need.
We have a walk out protocol in our A&E departments to alert agencies to
patients who may leave the department before an assessment can be completed so that we follow this through depending on initial risk
assessment to ensure their safety We have frequent flyer meetings between CRHT and A&E staff to review
patients who may have multiple presentations to A&E in crisis to review their overall care plan with a view to achieving greater stability and
support. Nationally, 1 in 5 admissions via unscheduled care are related to attempted suicide or self harm.
On our admission ward, we have the Citizen’s Advice Bureau (CAB) surgery as debt and the impact of financial reforms is one of the most
significant triggers for desperation within the local communities and can bring people into contact with our services. MIND have employed a PIP
worker to assist patients subject to benefit reform who are vulnerable to having essential benefits stripped away. Gofal are also commissioned to
provide a ‘Hospital to Home’ service to ensure patients tenancies are
maintained well they are in hospital. We have a mandatory 7 day follow up appointment for patients
discharged from in-patient care.
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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We are now delivering Dialectical Behaviour Therapy (DBT) for patients with personality disorder who are at significant risk of self harm. This is in
its first year so is yet to be evaluated locally but this treatment approach is evidence based with recognised positive outcomes for this client group
We have established Outreach and Recovery Community Services (7days
a week) to provide care and treatment for those with most complex needs who can difficult to engage.
Primary Care Mental Health services deliver stepped psycho-social interventions with a view to helping people manage mild to moderate
difficulties and building resilience.
It important to remember that only 19% of those adults who commit suicide have been known to Mental Health Services in the year preceding their death as
reported for 2015/16.
As well as the direct work undertaken by the Mental Health Directorate, the Health Board is supporting several initiatives that we anticipate will also support
a reduction in suicides among adults:
The Valleys Steps project will be heavily promoted to the general population and will aim to be non-stigmatising and easily accessible to hard to reach
groups. Several key aspects of the projects are based on ‘Glasgow Steps’
which has demonstrated best practice on engaging hard to reach groups, in particular, middle aged men who are often isolated and may have co-
occurring substance misuse issues. Targeted promotion of the service and the telephone call back service will support local engagement with the
specific groups where suicide appears to be on the increase.
The Samaritans ‘Valleys Project’ - we have also been supporting the development of a local suicide prevention project being undertaken by the
Samaritans. The project manager is now in plan and is undertaking a local scoping exercise with our support. The project aims to extend the
Samaritans presence into Cwm Taf, raise awareness of they involvement in reducing suicide and recruit local volunteers so that they can deliver a
sustainable local service. Areas we are encouraging them to focus the project on include:
– Engaging the ‘hard to reach’ members of our local population – A highly accessible and visible service to support our crisis and A&E
services and particularly ‘frequent flyers and self harmers’ – Outreach to food banks and other community based services
– ‘Feet on the Street’ – this works well in other welsh town centres and could be piloted in Pontypridd and Merthyr Tydfil
– Work to review ‘hot spots’ such as local railways and bridges – the Samaritans have undertaken this type of work with other Local
Authorities and Network Rail in other parts of Wales.
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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3) Strategic Developments
The Health Board has also been involved in attempting to establish a regional Suicide and Self Harm Prevention group (as required within the ‘Talk to Me’ and
Talk to Me 2’ action plans) with Cardiff and the Vale UHB. A highly successful
multi agency conference was hosted by Cwm Taf in July 2014 to support this development. The conference was well represented by health, local authority,
emergency services, the third sector and service users with over 70 participants attending. The key themes that were identified as priorities for the regional
group included: – Training and awareness raising
– Data and information sharing – Communication and signposting
– Prevention and intervention – Managing the consequences of suicide and self harm
Following the launch of the ‘Talk to Me 2’ (June 2015) and its accompanying
action plan, leads from the Cwm Taf, Cardiff and Vale and Aneurin Bevan UHB areas met to confirm arrangements for the South East Wales Regional Multi-
Agency Suicide Prevention Forum (SEWRMASPA).
Locally, developments in relation to reducing suicide and self harm among
adults are fed back via the Cwm Taf ‘Together for Mental Health’ Partnership Board.
4. RECOMMENDATION
The Mental Health Act Monitoring Committee is asked to:
DISCUSS the higher levels of suicide in the Cwm Taf region and the actions aimed at reduction
Freedom of information status
Open
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6 Year analysis update of reported suicide in Cwm Taf
April 2010 – March 2016
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AGENDA ITEM 2.2
15 June 2017
Mental Health Act Monitoring Committee Report
MENTAL HEALTH ACT MONITORING COMMITTEE
DRAFT ANNUAL REPORT 2016-17
Executive Lead: Director of Primary, Community and Mental Health
Author: Head of Corporate Services
Contact Details for further information: [email protected] or 01443 744911
Purpose of the Mental Health Act Monitoring Committee Report
To present to the Mental Health Act Monitoring Committee the draft
Annual Report, that provides an overview of the work undertaken by the Committee during the year and sets out how it met its Terms of
Reference.
Governance
Link to Health
Board Strategic Objective(s)
The Board’s overarching role is to ensure its Strategy
outlined within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related
organisational objectives aligned with the Institute of
Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:
To improve quality, safety and patient experience
To protect and improve population health To ensure that the services provided are
accessible and sustainable into the future To provide strong governance and assurance
To ensure good value based care and treatment for our patients in line with the resources made
available to the Health Board. This report aims to support all of the strategic
objectives.
Supporting evidence
Information from the Committee’s work for 2015/16
Engagement – Who has been involved in this work?
The Chair of the Committee, Director of Primary Community and Mental
Health, Mental Health Act Monitoring Committee members and secretariat.
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Mental Health Act Monitoring Committee Resolution To:
APPROVE √ ENDORSE DISCUSS NOTE
Recommendation Members of the Mental Health Act Monitoring
Committee are asked to: DISCUSS and APPROVE the report for
submission to the Health Board. Complete the Self Assessment
Questionnaire for the Committee (Attached as Appendix 2)
Summarise the Impact of the Mental Health Act Monitoring
Committee Report
Equality and
diversity
This report is a summary of the work of the
Committee over the past year. There are no specific equality and diversity issues
Legal implications There are no specific legal implications
Population Health This report does not impact on population health
Quality, Safety & Patient Experience
This report does not impact on the quality, safety and patient experience although the aim of the
Committee’s work to assure the Board that Mental Health services are performing in
accordance with the Mental Health Act which directly impacts on patient care.
Resources This report outlines the work of the Committee
over the past year
Risks and Assurance The risks and assurance forms the key part of
the Committee’s work over the past year
Health & Care
Standards
The 22 Health & Care Standards for NHS Wales
are mapped into the 7 Quality Themes:
Staying Healthy Safe Care
Effective Care Dignified Care
Timely Care Individual Care
Staff & Resources http://www.wales.nhs.uk/sitesplus/documents/1
064/24729_Health%20Standards%20Framework_2015_E1.pdf
The work of the Committee over the past year reported in this summary takes into account
many of the related quality themes.
Workforce There are no workforce issues in this report
Freedom of information status
Open
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MENTAL HEALTH ACT MONITORING COMMITTEE
DRAFT ANNUAL REPORT 2016-17
1. SITUATION / PURPOSE OF REPORT
INTRODUCTION
The Mental Health Act Monitoring Committee is chaired by the Vice Chair
of the Health Board and monitors the Health Board’s compliance with the statutory requirements of the Mental Health Act. The work of this
Committee, including its Terms of Reference, has been reviewed and refreshed during the year and related processes and focus has been
strengthened. This has led to changes to the standard format and agenda for the Committee which has evolved to an agreed position over the year.
A key change to the Committee this year coincided with the University
Health Board move towards a paperless solution to increase transparency
and openness for members of the public to be able to access the business of the Committee. Since December 2016, the papers for the meeting are
routinely shared on the website one week before the meeting is due to take place; papers are available using this link:
http://cwmtaf.wales/mental-health-act-monitoring-committee/ .
The Committee meets on a quarterly basis. Issues are also reported on an exception basis to the Integrated Governance Committee by the
Committee Chair. There is also the opportunity to refer key risks back to the Health Board or through reports from the Committee Chair at full
Board meetings. Broader Mental Health issues are discussed and taken forward via other established fora such as the Together for Mental Health
Partnership Board (which is chaired by the Vice Chair of the Health Board).
MEMBERSHIP
The membership of the Mental Health Act Monitoring Committee comprises both Independent and Executive Members, enabling the
Committee to provide appropriate scrutiny and assurance to the Board independently of the management decision-making processes.
Independent membership during 2016-17 was as follows:
Prof Donna Mead, who also Chairs the meeting Mr Trevor Davis, Associate Board Member (in attendance from
December 2015 meeting and his last meeting was the 19 September 2016).
Executive Director member of the Committee was as follows:
Mr John Palmer, Director of Primary, Community and Mental Health.
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MEETINGS
The Mental Health Act Monitoring Committee met on 4 occasions during 2016-2017:
16 June 2016 15 September 2016
8 December 2016 16 February 2017.
Mental Health Act Monitoring Attendance 2016-2017
16 June
2016
19 Sept
2016
8 Dec
2016
16 Feb
2017
Meeting
/4
Prof Donna Mead Vice Chair, Cwm
Taf UHB (Chair)
√ √ X √ 3/4
Mr Mel Jehu Independent Member
√ 1st meet
√ √ √ 4/4
Mr John Palmer Director of Primary,
Community & Mental Health
√ √ √ √ 4/4
Mr Trevor Davis Associate Board
member
√ √
(Last)
2/2
Dr Paul Davies
(PhD)
Assistant Director
of Operations
√ √ √ √ 4/4
Supt Jim Dyson South Wales Police √ √ √ X 3/4
DI Peter Thomas South Wales Police X √ √ √ 3/4
Dr Adarsh Shetty Clinical Director X √ X √ 2/4
Mr Phil Lewis Head of Nursing AMH
X √ X X 1/4
Ms Sam Shore Senior Nurse √ X X √ 2/4
Mrs Pamela Connor MHA Administrator √ √ √ X 3/4
Ms Gail Holloman Representative
RCT CBC
√ X X √ 2/4
Mr Mark Anderton Merthyr Tydfil CBC X √ X √ 2/4
Mrs Julie Cude Head of Nursing
CAMHS
X √ √ X 2/4
Dr Tracy Gardiner Clinical Director CAMHS
X X X X 0/4
Mr Gregory Lloyd WAST X X X X 0/4
Ms Jane Treharne Davies
Carer representative
X X X X 0/4
Mr Robert Williams Board Secretary X X √ X 1/4
Miss Gwenan Roberts
Head of Corporate Services
√ √ √ √ 4/4
Miss Kate Bowd Secretariat √ √ X √ 3/4
Ms Chrystelle Walters
Senior Nurse CAMHS
√
Mr Colin Hatherley South Wales Police √
Mr Roger John WAST √
Dr Peter Halford CAMHS √
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During 2016-2017 slight amendments were made to the Terms of Reference in relation to staff ‘in attendance’ at the Committee meetings,
including identifying minimum attendance expectations as follows:
In attendance: Representatives from South Wales Police
Representative from Rhondda Cynon Taf County Borough Council Representative from Merthyr Tydfil County Borough Council
Chair of Mental Health Act Monitoring Operational Group Head Administrator - Mental Health Act Administration Team
Carer Representative from the Together for Mental Health Partnership Board
Representative from Welsh Ambulance Services Trust (minimum
twice per annum) Clinical Director for Mental Health (minimum twice per annum)
Head of Nursing for Mental Health (minimum twice per annum) Clinical Director, Child & Adolescent Mental Health Service (CAMHS)
(minimum twice per annum) Head of Nursing CAHMS (minimum twice per annum)
During the review of the Terms of Reference the those required to ensure
that each meeting was quorate was agreed as: one Independent Member
the Director of Primary, Community and Mental Health or the Assistant Director
a representative from the partner organisations either from the South Wales Police, Local Authorities or the Welsh Ambulance
Services NHS Trust and
at least one clinical representative.
2. BACKGROUND / INTRODUCTION
The purpose of Cwm Taf University Health Board’s Mental Health Act
Monitoring Committee is to ensure that all the requirements of the Mental Health Act 1983 (as amended) are met by the Health Board.
The Committee shall consider:
how the delegated functions under the Mental Health Act are being exercised (for example using the Annual Audit) and in line with the
‘Code of Practice’ requirements the multi agency training requirements of those exercising the
functions (including discussing the training report for assurance) the operation of the 1983 Act within the Cwm Taf area
issues arising from the operation of the hospital managers’ power of discharge
a suitable mechanism for reviewing multi agency protocols / policies relating to the 1983 Act
trends and patterns of use of the Mental Health Act 1983
cross-agency audit themes and sponsor appropriate cross-agency audits
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lessons learnt from difficulties in practice and the development of areas of good practice
Develop an annual report for presentation to the Health Board.
MAIN AREAS OF MHAM COMMITTEE ACTIVITY
The agenda for each meeting has followed a standard format in five main
parts: Part 1 - Preliminary Matters
Part 2 - Items for Discussion Part 3 - Governance, Performance and Assurance
Part 4 - For Information Part 5 - Other Matters.
Part 1 - Preliminary Matters
This section of the meeting provides the standard governance approach
within all sub committees of the Board within Cwm Taf University Health Board. This includes the action log which captures all areas for attention
following the meeting. The Chair provides an oral report at every meeting.
Part 2 - Items for Discussion
This section has included receiving the:
Committee Annual Report Operational delivery plan Section 136 Crisis Concordat
Terms of Reference.
Part 3 - Governance, Performance and Assurance
This section has included papers in a standardised format throughout the year which included:
Mental Health Act – Quarterly Activity Statistical Report Mental Health Crisis Care Concordat
Mental Health Act Breaches / Analysis of Unlawful detention - this
report was changed during the year to assist the reader in identifying the levels of breaches in the categories of the Mental
Health Act (including the Annual Report on 8 December 2016) Risks related to the monitoring of the Mental Health Act (Oral)
In December an oral report on the national approach to reporting Mental Health Act Breaches was received.
During the year a change took place to the reporting of the Mental Health
Crisis Care Concordat and the Health Board and South Wales Police worked together to ensure that the data related to the Mental Health Act
Monitoring was aligned. The Committee also agreed to receive a written report from South Wales Police related to Section 136 at each meeting,
which was very well received by Members.
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The Risk Register for risks identified for this Committee would also be presented within this section of the agenda – no organisational risks from
the Cwm Taf Organisational Risk Register were identified during the year.
Part 4 - For Information
The following items have been shared with the Committee for information sharing purposes:
Adult Mental Health Performance Report received at the Finance, Performance & Workforce Committee (June 2016; September 2016;
December 2016 and February 2017) HIW Inspection Reports (oral report in June 2016)
- Community Treatment Orders (September 2016)
- Joint Health Inspectorate Wales / CSSIW inspection of Learning Disabilities in Merthyr Tydfil (September 2016)
- All Wales overview of Joint HIW/CSSIW inspection of learning disabilities (September 2016)
Mental Health Act 1983 – Code of Practice for Wales Her Majesty’s Inspectorate of Constabulary (December 2016)
CAMHS Performance Report received at the Finance, Performance & Workforce Committee (February 2017)
National Approach to Mental Health Breaches (latest draft) (February 2017).
Part 5 - Other Matters
The ‘Forward Look’ plan for the Committee is reviewed at each meeting to
ensure that it is still targeted at the appropriate risk areas.
Links with Other Committees/Boards
Key risk areas from the Mental Health Act Monitoring Committee can also
be highlighted at Integrated Governance and/or full Board by the Chair of the Committee.
During the course of the year, no matters have been referred to other
Committees.
Key elements are also taken into account at the Quality, Safety and Risk Committee; this linkage is made by the Director of Governance and
Corporate Services / Board Secretary.
Action Log
In order to monitor progress and any necessary follow up action, the
Committee has developed an Action Log that captures all agreed actions. This has provided an essential element of assurance both to the
Committee and from the Committee to the Integrated Governance Committee and the Board.
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3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
GOVERNANCE
The Committee provides an essential element of the overall governance
framework for the organisation and intends to develop its function still further in the forthcoming year. The Terms of Reference for the
Committee provide a robust commitment to monitor the application of the Mental Health Act – these were approved by the Cwm Taf University
Health Board on 18 January 2017 (attached as Appendix 1).
ASSURANCE TO THE BOARD
The Mental Health Act Monitoring Committee wishes to assure the Board that on the basis of the work completed by the Committee during
2016/16, there are effective measures in place to monitor the application of the Mental Health Act and to effectively scrutinise and monitor this
important area.
The position over the last year related to the breaches of the Mental
Health Act has highlighted 84 breaches of the Act, the majority identified as administration breaches. The table below summarises the categories
from the Annual Report of the MHA Breaches.
Cat 1 Cat 2 Cat 3 Cat 4 Frequency 75 6 0 3
Category 1 Administration Breaches within 14 days
Category 2 Incorrect applications of the Act but corrected within14 days
Category 3 Incorrect applications of the Act but not corrected within 14 days
Category 4 Incorrect applications of the Act and not corrected
The number of the most serious Category 4 has reduced from 11 in the
previous reporting period to 3.
All incidents are now reported on Datix and these are investigated and lessons learnt taken into the service. Over the year the Committee have
noted that the consistent theme of simple errors made by medical staff on the application forms would be taken forward by the Clinical Director as an
action for improvement with medical professional staff. It was noted that
the breaches were a mix of errors made by all staff involved in the patient pathway including medical staff, social work staff and administration staff.
This will continue to be an area for focus and determination.
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4. RECOMMENDATION
Members of the Mental Health Act Monitoring Committee are asked to:
DISCUSS and APPROVE the report for submission to the Health Board
Complete the Self Assessment Questionnaire for the Committee (Attached as Appendix 2)
Freedom of
information status
Open
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MENTAL HEALTH ACT MONITORING COMMITTEE
TERMS OF REFERENCE
INTRODUCTION
The Standing Orders provide that “The Board may and, where directed by
the Welsh Government must, appoint Committees of the Health Board either to undertake specific functions on the Board’s behalf or to provide
advice and assurance to the Board in the exercise of its functions. The Board’s commitment to openness and transparency in the conduct of all
its business extends equally to the work carried out on its behalf by committees”.
In accordance with Standing Orders (and the Health Board scheme of delegation), the Board shall nominate a committee to be known as the
Mental Health Act Monitoring Committee - “the Committee”. The detailed terms of reference and operating arrangements set by the Board in
respect of this Committee are set out below.
CONSTITUTION
The Board hereby resolves to establish a Committee of the Board to be
known as the Mental Health Act Monitoring Committee (The Committee).
The Committee is an Independent Member Committee of the Board and has no executive powers, other than those specifically delegated in these
Terms of Reference.
SCOPE AND DUTIES
The Health Board should determine any necessary arrangements to
monitor and review the way functions under the Act are exercised on its behalf, it may authorise a committee, or sub-committee, for this purpose
with a process of reporting on findings. The Committee shall consider:
how the delegated functions under the Mental Health Act are being exercised (for example using the Annual Audit) and in line with the
‘Code of Practice’ requirements
the multi agency training requirements of those exercising the functions (including discussing the training report for assurance)
the operation of the 1983 Act within the Cwm Taf area
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issues arising from the operation of the hospital managers’ power of discharge
a suitable mechanism for reviewing multi agency protocols / policies relating to the 1983 Act
trends and patterns of use of the Mental Health Act 1983 cross-agency audit themes and sponsor appropriate cross-agency
audits lessons learnt from difficulties in practice and the development of
areas of good practice Develop an annual report for presentation to the Health Board.
AUTHORITY
The Committee is authorised by the Board to:
- investigate or have investigated any activity within its Terms of Reference and in performing these duties shall have the right, at all
reasonable times, to inspect any books, records or documents of the
Health Board. It can seek any information it requires from any employee and all employees are directed to co-operate with any
request made by the Committee - obtain outside legal or other independent professional advice and to
secure the attendance of outsiders with relevant experience and expertise if it considers this necessary, subject to the Board’s
budgetary and other requirements - by giving reasonable notice, require the attendance of any of the
officers or employees and auditors of the Board at any meeting of the Committee.
SCHEME OF DELEGATION
Hospital Managers may arrange for their functions under the Mental Health Act to be carried out on a day to day basis by particular Officers on
their behalf. (COP 11.7) The arrangements for authorising decisions has been set out in a scheme of Delegation and this is included at Appendix
1.
MEMBERSHIP
The 1983 Act is operated by health and social care practitioners, in
collaboration with a range of agencies including police and ambulance services, as well as third sector bodies such as advocacy providers.
Membership of the Committee should reflect this, as different agencies
and practitioners have differing responsibilities and duties under the Act.
The Vice Chair of the Health Board shall Chair the Committee given their specific responsibility for overseeing the Health Board performance in
relation to mental health services and the following shall be members:
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Two Independent Board Members (one of which would be the Chair of the Committee)
Director of Primary, Community & Mental Health
In attendance: Representative from South Wales Police
Representative from Rhondda Cynon Taf County Borough Council Representative from Merthyr Tydfil County Borough Council
Chair of Mental Health Act Monitoring Operational Group Head Administrator - Mental Health Act Administration Team
Carer Representative from the Together for Mental Health Partnership Board
Representative from Welsh Ambulance Services Trust (minimum
twice per annum) Clinical Director for Mental Health (minimum twice per annum)
Head of Nursing for Mental Health (minimum twice per annum) Clinical Director, Child & Adolescent Mental Health Service (CAMHS)
(minimum twice per annum) Head of Nursing CAHMS (minimum twice per annum)
If members are unable to attend, a fully briefed and appropriately senior
deputy should be sent, wherever possible.
Support to Committee Members
The Director of Governance and Corporate Services / Board Secretary, on behalf of the Committee Chair, shall:
determine the secretarial and support arrangements for the Committee;
Arrange the provision of advice and support to committee members on any aspect related to the conduct of their role; and
Co-ordinate the provision of a programme of organisational development for committee members.
COMMITTEE MEETINGS
Quorum
This will comprise of one Independent Member, the Director of Primary, Community and Mental Health or the Assistant Director; a representative
from the partner organisations either from the South Wales Police, Local Authorities or the Welsh Ambulance Services NHS Trust and also at least
one clinical representative.
Frequency of Meetings
Meetings shall be held not less than three times a year. The Committee
will arrange meetings to fit in with key statutory requirements during the year consistent with the Health Board’s annual plan of Board Business.
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Circulation of Papers
Papers will be distributed at least 5 working days prior to each meeting.
REPORTING AND ASSURANCE ARRANGEMENTS
The Committee Chair shall:
report formally, regularly and on a timely basis to the Board on the Committee’s activities. This includes oral updates on activity, the
submission of committee minutes and written reports, as well as the presentation of an annual report;
bring specific attention to any significant matters under consideration
by the Committee via the submission of the minutes as part of the Committee Chairs and Champions Report to the Health Board;
ensure appropriate escalation arrangements are in place to alert the Chair, Chief Executive or Chairs of other relevant committees of any
urgent / critical matters that may affect the operation and / or reputation of the Health Board.
The Director of Governance and Corporate Services / Board Secretary, on
behalf of the Board, shall oversee a process of regular and rigorous self assessment and evaluation of the Committee’s performance and
operation.
RELATIONSHIP WITH THE BOARD AND ITS COMMITTEES /
GROUPS
The Chair of the Mental Health Act Monitoring Committee and the Director of Primary, Community and Mental Health will meet with their
counterparts on the Audit Committee, Quality, Safety & Risk Committee as part of the Integrated Governance Committee on at least an annual
basis to plan the agenda and agree what issues are being considered by each Committee and the timescales involved. A meeting will also be held
to review progress mid year.
The Committee, through the Committee Chair and members, shall
maximise cohesion and integration across all aspects of governance and assurance through the:
- joint planning and co-ordination of Board and Committee business; - sharing of information, as appropriate.
The Committee shall embed the Health Board’s corporate standards,
priorities and requirements, e.g. equality and human rights through the conduct of its business.
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Mental Health Act Monitoring Committee Meeting
15 June 2017
P a g e 14 of 15
Related (but not reporting) Sub Groups Mental Health Act Monitoring Operational Group
Together for Mental Health Partnership Board
APPLICABILITY OF STANDING ORDERS TO COMMITTEE BUSINESS
The requirements for the conduct of business as set out in the Health
Board’s Standing Orders are equally applicable to the operation of the Committee, except in relation to the Quorum.
REVIEW
These Terms of Reference shall be adopted by the Mental Health Act Monitoring Committee at its first meeting and subject to review at least on
an annual basis thereafter.
Approved by the Board on 18 January 2017
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Appendix 1 CWM TAF HEALTH BOARD
Mental Health Directorate Hospital Managers’ Scheme of Delegation
COP 11.7 Hospital Managers may arrange for their functions to be
carried out on a day-to-day basis by particular people on their behalf.
COP 11.8 The arrangements for authorising decisions should be set out in a scheme of delegation approved by a resolution of the
body itself.
Sections of
MHA 1983
Issue/Task Delegated to
4, 2, 3 Admission to hospital: Record of
detention in hospital
MHA Administrator /
Nurse in Charge or Senior Nurse
5(2) Report on hospital inpatient MHA Administrator / Nurse in Charge or
Senior Nurse
21B Authority for detention after absence without leave for more than 28 days
(hospital or community patient)
MHA Administrator
20 Renewal of authority to detain
Hospital Managers Committee,
MHA Administrator
COP 11.15
Ensuring appropriate RC for patient
Clinical Governance Committee
19 Transfer between hospitals under
different managers
MHA Administrator /
Nurse in Charge or Senior Nurse.
19 Transfers into/from guardianship MHA Administrator /
Nurse in Charge or Senior Nurse
MHA 1983
Part 6
Date of reception of a patient into hospital in Wales
MHA Administrator / Nurse in charge or
senior nurse
MHA 1983
Part 6
Transfer of patient subject to compulsion in the community
MHA Administrator / Nurse in charge or
senior nurse
19A Authority for assignment of
responsibility for a community patient
from one hospital to another under
MHA Administrator
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Sections of
MHA 1983
Issue/Task Delegated to
different managers
17E Record of detention of recalled
community patient
MHA Administrator /
Nurse in Charge or Senior Nurse
17F Authority for transfer of a recalled
community patient to a hospital under different managers
MHA Administrator /
Nurse in charge or senior nurse
20A Report extending CT period MHA Administrator
132, 132A,
133
Information for patients and nearest relatives refer to chapter 11 COP for
Wales
MHA Administrator/ Nurse in Charge or
Senior Nurse
S20 Renewal of authority for detention MHA Administrator
68 Referral to MHRT for patients subject to
the Mental Health Act 1983
MHA Administrator
COP 26.27
Responsible Clinician acting as the nominated representative of the
responsible authority
Responsible Clinician
COP
11.35
Informing LHBs and LSSAs of MHRT
hearings so they can consider s117 needs
MHA Administrator
67 Referrals by Welsh Ministers to MHRT MHA Administrator
25 Report barring discharge by Nearest Relative
MHA Administrator
S48 / Schedule
6
Domestic Violence Crime and Victims Act 2004
RC, MHA Administrator
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1
BOARD-COMMITTEES: SELF ASSESSMENT CHECKLIST 2016/17
The primary purpose of this annual self assessment is to consider the effectiveness of the Committee. It also includes a section on you and your
role on the Committee. Committee Name - MENTAL HEALTH ACT MONITORING COMMITTEE
Yes
(√)
No
(√)
Don’t
Know
(√)
Comments
Part A (The Committee)
Composition and Establishment
1. Does the Committee have written terms of reference that adequately and accurately define
its role, purpose and accountabilities?
2. Have the terms of reference been adopted by the Board?
3. Are the terms of reference reviewed annually to
ensure they remain fit for purpose?
4. Does the Committee have an annual work plan in place?
If yes, is it reviewed regularly?
5. Has the Committee been provided with sufficient
membership, authority and resources to perform its role effectively and objectively?
6. Does the Committee have the requisite number (4) of Non Officer Members?
7. Does the Committee monitor its attendance?
8. Is the Committee membership appropriate, in terms of available skills, expertise? If no, please elaborate within comments section.
Effective Functioning - Committee
9. Is there effective scrutiny and challenge from all Committee Members?
10. Does the board review the progress and outputs
of the Committee?
11. Does the Committee report regularly to the Board verbally and through minutes and make clear recommendations when necessary?
12. Does the Committee periodically assess its own
effectiveness?
13. Can members give appropriate feedback on the effectiveness of the Chair and the Secretary?
14. Has the Committee determined the appropriate
level of detail it wishes to receive from reports?
15. Does the Committee receive the appropriate level of timely and accurate information to allow it to fulfil its role?
16. Does the Committee have sufficient time to cover its business?
17. Does the committee effectively monitor – or ensure monitoring of - agreed actions? e.g. by use of the action grid
18. Are members particularly those new to the Committee, provided with training?
19. Has the Committee formally considered how it integrates with other committees and groups?
20. Where they exist, does the Committee receive timely and appropriate feedback from its sub-groups ?
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2
Yes
(√)
No
(√)
Don’t
Know
(√)
Comments
21. Does the Committee provide clear direction to its
sub-groups?
22. Does the Committee produce an Annual Report of its work?
23. If yes (to Q 22) - Do all members contribute to and review the committee’s Annual Report?
Compliance with the law and regulations governing the NHS
24. Does the committee have a mechanism to keep it aware of topical issues?
25. Does the committee have a mechanism to keep it aware of any related legal / regulatory
guidance?
Assurance 26. Does the committee receive timely exception
reports about the work of external regulatory and inspection bodies?
27. Does the committee receive timely information on performance concerns?
28. Are all these reports clear, concise, readily understood?
29. Is the Committee able to refer matters outside its own jurisdiction and if yes, is any feedback reviewed on such matters?
30. If considered appropriate, does the Committee escalate matters to the Integrated Governance
Committee?
31. If considered appropriate, does the Committee
know the process to be followed should it need to escalate matters to the Board?
32. In relation to the Board Assurance Framework and the Organisation’s Risk Register, does the Committee appropriately review the risks assigned to it?
Other Issues
33. Does the committee meet the appropriate number of times to deal with planned matters, development and liaison?
34. Are arrangements in place to call ad hoc meetings when necessary?
35. Are committee members notified of urgent matters when appropriate?
36. Does the committee make the organisation aware of issues of staff capacity and skills that impact on the running of the committee?
Administrative arrangements
37. Is the committee aware of the costs of its operation?
38. Are the Committee’s costs appropriate to the perceived risks and benefits?
39. Are papers circulated in good time and are minutes and agreed actions, received as soon as possible after meetings?
Questions for Consideration & Discussion
40. How does the Committee ensure that its work is fully conveyed to the Board and wider organisation?
41. Is the work of the committee duplicated elsewhere in the organisation? if yes, please elaborate.
42. Do you consider the Committee to be effective in
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Yes
(√)
No
(√)
Don’t
Know
(√)
Comments
discharging its terms of reference?
43. Do you have any suggestions on how the work of the Committee could be improved or strengthened?
PART B - Effective Functioning - individual members
44. What is your role on the Committee? Non officer member Officer member Executive Director
Senior Manager External stakeholder
Other
45. Do I have sufficient understanding and knowledge of the issues covered within the terms
of reference of the Committee?
46. Do I appropriately challenge Executives and management on critical and sensitive matters?
Please return completed self assessment checklist to Robert Williams
2.2.1 Appendix 2 Committee Self Assessment Questionnaire
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MHA Monitoring Report
Quarter 4 Activity Report Jan-Mar 2017
Page 1 of 14 Mental Health Act Monitoring
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AGENDA ITEM 3.1
16 February 2017
Mental Health Act Monitoring Committee Report
QUARTER 4 ACTIVITY REPORT FOR
JANUARY 2017 TO MARCH 2017
Executive Lead: Director of Primary Care, Community and Mental Health Services
Author: Assistant Director of Operations (Mental Health) and Mental Health Act Administration team
Contact Details for further information: Dr Paul Davies (PhD)
Assistant Director Operations [email protected] 01443 443700
Purpose of the Mental Health Act Monitoring Committee Report
A report of Mental Health Act (MHA) activity to the Mental Health Act
Monitoring Committee regarding Quarter 4 and (January to March 2017).
Governance
Link to Health Board Strategic
Objective(s)
The Board’s overarching role is to ensure its Strategy outlined within ‘Cwm Taf Cares’ 3 Year Integrated
Medium Term Plan 2015-2018 and the related organisational objectives aligned with the Institute of
Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:
To improve quality, safety and patient experience.
To protect and improve population health. To ensure that the services provided are
accessible and sustainable into the future. To provide strong governance and assurance.
To ensure good value based care and treatment for our patients in line with the resources made
available to the Health Board.
This report focuses mainly on providing strong governance and assurance.
Supporting evidence
Performance data A glossary of terms is attached at Appendix 1.
Engagement – Who has been involved in this work?
Staff in the Mental Health Directorate
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Mental Health Act Monitoring Committee Resolution To;
APPROVE ENDORSE DISCUSS √ NOTE √
Recommendation The Mental Health Act Monitoring Committee is requested to:
DISCUSS and NOTE the report.
Summarise the Impact of the Mental Health Act Committee Report
Equality and diversity
No specific equality and diversity issues have been identified.
Legal implications This report presents the local implementation trend of the MHA.
Population Health No specific impact.
Quality, Safety &
Patient Experience
It is necessary to ensure there is no adverse use
of the MHA sections with Cwm Taf UHB
Resources The report is produced quarterly for the Adult
Mental Health MHA Operational group
Risks and Assurance The report does not present any overt risks
Health & Care Standards
The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:
Staying Healthy
Safe Care Effective Care
Dignified Care Timely Care
Individual Care Staff & Resources
http://www.wales.nhs.uk/sitesplus/documents/1
064/24729_Health%20Standards%20Framework_2015_E1.pdf
The work reported in this summary and related
annexes take into account many of the related quality themes
Safe Care
Dignified Care
Workforce Some added work due to the West Cheshire
judgement (increase in administration)
Freedom of
information status
Open
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QUARTER 4 ACTIVITY REPORT FOR JANUARY 2017 TO MARCH 2017
1. SITUATION /PURPOSE OF REPORT
The purpose of this report is to present activity data regarding the application of the Mental Health Act (1983) within Cwm Taf University Health Board. A
glossary of terms is attached for ease of reference at Appendix 1. This report presents the Mental Health Act (MHA) activity to the Mental Health Act
Monitoring Committee in respect of Quarter 4 (January to March 2017) for discussion and scrutiny.
2. BACKGROUND
The report covers both Adult Mental Health and Children and Adolescent Mental
Health (CAMHS) services managed by Cwm Taf University Health Board.
Activity is regularly monitored in the operational (adult) Mental Health
Committee chaired by the Senior Nurse Samantha Shore, supported by the Mental Health Act administration office team and information is reported via the
Assistant Director of Operations to the monthly operational Mental Health Clinical Governance Committee.
3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
IN-PATIENT MHA ACTIVITY
Number of Adult compulsory admission under the Mental Health Act
1983 for Quarter 4 (January to March 2017)
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Section Q4 Q3
Section 5(4) 2 0
Section 5(2) 26 17
Section 4 1 4
Section 2 37 33
Section 3 22 22
Section 37 1 0
Section 37/41 0 1
TOTAL 89 77
ADULT DETENTION BY AREA
Area Q4 Q3
Merthyr Tydfil 15 12
Cynon 20 18
Taff 19 14
Out of area 6 3
Rhondda 29 30
Number of Older Persons compulsory admission under the Mental Health Act 1983 for Quarter 4 (January to March 2017)
Section Q4 Q3
Section 5(4) 0 1
Section 5(2) 7 7
Section 4 1 0
Section 2 21 20
Section 3 13 9
Section 37 0 0
Section 37/41 0 0
TOTAL 42 37
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OLDER PERSONS DETENTION BY AREA
Area Q4 Q3
Merthyr Tydfil 12 5
Cynon 8 12
Taff 13 11
Out of area 0 2
Rhondda 9 7
Number of CAMHS patients compulsory admission under the Mental Health Act 1983 for Quarter 4 (January To March 2017)
Section Q4 Q3
Section 5(4) 0 0
Section 5(2) 6 1
Section 4 0 0
Section 2 7 2
Section 3 1 2
TOTAL 14 5
Number of ALL patients compulsory admission under the Mental Health Act 1983 for Quarter 4(Section 4, 2 and Section 3 only)
There were 103 detentions in quarter 4 compared to 92 in Quarter 3.
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DISCHARGES BY RESPONSIBLE CLINICIANS
Section 23 of the Mental Health Act 1983 provides for the Responsible Clinician (RC) to discharge a detained patient from certain detention orders by giving an
order on a statutory form.
Section Q4 Q3
Adult 2 24 25
4 0 1
3 10 9
Older Persons 2 15 9
4 0 0
3 11 8
CAMHS 2 7 2
4 0 0
3 3 0
TOTAL 70 54
SECTION LAPSING
Section Q4 Q3
Adult 2 1 2
4 0 0
3 0 0
Older Persons 2 0 0
4 0 0
3 0 0
CAMHS 2 0 0
4 0 0
3 0 0
TOTAL 1 2
TRANSFER BETWEEN HOSPITALS
Section 19 of The Mental Health Act allows for the transfer of Part 2 (Section 2, 3 and CTO Patients) and some Part 3 (Section 37,37/41, 47, 47/49 and 48/49)
detained patients from a hospital under one set of managers to a hospital under
a different set of managers. For restricted patients transfers are subject to the prior agreement of the Secretary of State.
SECTION Q4 Q3
Part 2 Patients T0 CTUHB 5 0
Part 3 patients to CTUHB 0 0
Part 2 patients from CTUHB 4 5
Part 3 patients from CTUHB 0 0
TOTAL 9 5
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MANAGERS HEARING
Under the provisions of the Mental Health Act 1983, detained patients have a right to have their detention reviewed by the Hospital Managers. The Hospital
Managers responsibilities are as follows:
Undertake a review of detention at any time Must review a patient’s detention when Responsible Clinician (RC) submit
a report under Section 20 renewing detention and community treatment orders
Must consider holding a review when a patient requests it Must consider holding a review when the RC makes a report under
Section 25 (1) opposing a nearest relative application for the patient’s discharge
Hospital Managers Hearing Q4 Q3
Number of review requested by Hospital Managers 0 0
Number of renewal of authority to detain considered by Hospital Managers during the period
15 13
Number of Section 2 hearings requested by patient 2 0
Number of Section 3/37 hearings requested by patient
2 1
Number of Section 2 hearings following RC barring of
application by nearest relative to discharge patient.
0 0
Number of Section 3 hearings following RC barring of
application by nearest relative to discharge patient.
0 1
Number of renewals of CTO considered by Hospital
Managers during this period
8 20
Number of CTO hearings requested by patient 0 0
Number of CTO hearings following RC barring of
application by nearest relative to discharge patient
0 0
Total number of hearing arranged in that period 27 35
Total number of hearing heard in that period 25 28
Total number of hearings arranged in period
that were not heard and reasons: Patient discharged by RC prior to hearing
Request for additional info requested by legal rep Adjourned
Postponed Patient discharged subject to CTO therefore no
longer required Communication error
Transferred prior to hearing Other
1
1
7
3
2
1
1
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TRIBUNAL HEARINGS
The Mental Health Review Tribunal for Wales is a statutory body which works independently of the Health Board to review appeal made by detained patients
for discharge from their detention and community orders under the Mental
Health Act 1983. Patients are also referred by the Hospital Managers within define period as set in the MHRT Tribunal rules 2008.
Mental Health Review Tribunal Hearings Q4 Q3
Referrals made by Hospital Managers to MHRT 6 6
Tribunal requested by patient (Section 2) 10 20
Tribunal requested by patient (Section 3/37) 8 7
Tribunal requested by patient (Section 7) 0 0
Tribunal request by patient (Section 37/41) 1 2
Tribunal requested by patient (CTO) 0 0
Tribunal requested by nearest relative 0 0
Referrals by Secretary of State to MHRT 0 0
Total number of MHRT arranged 25 35
Total number of hearings heard 17 14
Total number of hearings not heard and
reasons
Discharged by Responsible Clinician Withdrawn by patient
Transferred prior to hearing Adjourned
8
4 1
1 2
21
13 5
0 3
COMMUNITY ACTIVITY
COMMUNITY TREATMENT ORDER (CTO)
Section Power Q4 Q3
17 A Community Treatment Order made in this quarter
6 5
Community Treatment order extended in
this quarter
6 13
Recalled to hospital and not admitted in
this quarter
1 0
Recalled to hospital and revoked in this quarter
2 2
Discharged from CTO this quarter 6 0
Transferred in this quarter 0 1
There are currently 33 patients subject to CTO
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CURRENT COMMUNITY TREATMENT ORDER BY AREA
Q4 Q3
Merthyr Tydfil 7 12
Cynon 8 7
Taff 8 8
Out of area 0 1
Rhondda 10 9
Bridgend 0 0
GUARDIANSHIP
Section 7
Power Q4 Q3
Guardianship made in this quarter 0 0
Discharged from Guardianship 0 0
Renewal of Guardianship 1 1
Guardianship lapsed 0 0
There are currently 3 patients subject to Guardianship
USE OF SECTION 135 AND SECTION 136 - REMOVAL TO A PLACE OF SAFETY
Section 135 of the Mental Health Act Q4 Q3
Assessed and admitted informally 0 0
Assessed and detained under Section 2 2 1
Assessed and detained under Section 4 0 0
Assessed and detained under Section 3 0 0
TOTAL 2 1
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Section 136 of the Mental Health Act Q4 Q3
Assessed and admitted informally 4 5
Assessed and detained under Section 2 6 8
Assessed and detained under Section 4 0 0
Assessed and detained under Section 3 0 0
Discharged no mental disorder 11 10
Discharged referred to community services 8 10
Other (Recall from CTO) 0 1
TOTAL 29 34
Q4 (January to March 2017) Q3 (October to December 2016)
Gender: Out of 29 Section 136 detention 62%
were male and 38% Were female
Gender: Out of 34 Section 136 detentions 65%
were male and 35% were female
Place of safety:
100 % of patients were taken to hospital as first place of safety
Place of safety:
94% of patients were taken to hospital as first place of safety and
6% to Police Station and subsequently to hospital for assessment.
Use of illicit substances:
4 patients were under the influence of alcohol whilst detained and all were
subsequently discharged as no mental disorder
2 patients were under the influence of drugs whilst detained and one was
admitted under Section 2 and the other discharged and referred to
community services.
1 patient was under the influence of both alcohol and drug and was
subsequently admitted voluntarily to hospital
In 8 cases it was not possible to
ascertain whether under the influence as not documented
Use of illicit substances:
11 patients were under the influence of alcohol whilst detained and 1 was
subsequently detained under Section 2, 2 informally,8 discharged.
2 patients were under the influence of drugs and 1 was subsequently recalled
from CTO and the other detained under Section 2
2 patients were under the influence of
both alcohol and drug both were subsequently discharged
Reasons for detention:
Out of 29 Section 136 66% relates to
direct threats of suicide and 34% relate to aggressive/odd behaviour in
a public place.
Reasons for detention:
Out of 34 Section 136 71% relate to
direct threat of suicide, 23% relate to aggressive/odd behaviour in public
places, 6% directly relate to alcohol consumption.
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SECTION 136 DETENTION BY AREA
Area Q4 Q3
Merthyr Tydfil 2 3
Cynon 7 9
Taff 9 9
Out of area 2 3
Rhondda 7 8
camhs 2 2
OTHER ACTIVITY
DEATH OF DETAINED PATIENT
The Mental Health Hospital Managers have a duty to report to Healthcare Inspectorates Wales any patients deceased subject to the Mental Health Act
within 72 hours of death. This applies to in-patients as well as community treatment order and guardianship patients. The Coroner must also be informed.
1 patient passed away whilst subject to Section 2 of the Mental Health Act in
this quarter.
REFERRALS TO INDEPENDENT MENTAL HEALTH ADVOCATE (IMHA) SERVICE FROM HEALTH STAFF
Ward / Area Q4 Q3
Seren 10 12
St. David’s 9 6
Enhanced Care Unit (ECU) 5 7
Fernhill 1 1
Cambrian 0 0
Ward 35 0 1
Ward 7 0 2
Admissions 1 4
Ward 21 3 3
Ward 22 5 3
Psychiatric Intensive Care Unit (PICU) 1 2
Supported Recovery Unit (SRU) 0 3
Pinewood 0 2
TOTAL 35 46
STAFF TRAINING
The Health Board training plan is jointly funded by Health and Local Authorities. The joint budget has been an average of £7,000 per year which provides 6
formal training sessions per year.
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Training subject areas Q4 Sessions
held
Q3 – sessions
held
Section 117 aftercare 1
Child and Adolescent Training
MHRT Training
Legal Update
Mental Capacity Act/Deprivation of Liberty Safeguards
DoLS
1
Revision of Code of Practice 1
Medication awareness
Community Treatment Orders
Mental Health Act sections
One to one Hospital Managers Training 1
Power of discharge Hospital Managers 1
Total number of sessions 3 2
3 Training Sessions were held in this quarter in relation to Hospital Managers power and discharge, section 117 aftercare and Hospital Managers Training.
Training attendance
Activity Title Date Approved Attended CTUHB RCTCBC MTCBC Other %
attendance
Changes to the
Code of Practice
in Wales
05/10
/16
80 65 35 22 5 3 80%
MHA/MCA Legal
update plus CTO
19/10
/16
81 61 33 26 2 0 75%
Managers
Hearings-Process
and preparation
04/01
/17
36 26 15 9 2 0 72%
Section 117
Ordinary
Residence
29/03
/17
63 62 32 24 5 1 98%
Training costs
The total cost of joint Mental Health Training for 2016/17 was £4502.15.
4. RECOMMENDATION
The Mental Health Act Monitoring Committee is requested to:
DISCUSS and NOTE the report.
Freedom of
information status
Open
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Appendix 1 MENTAL HEALTH ACT (1983)
GLOSSARY OF TERMS
SUMMARY OF COMMON SECTIONS OF THE MENTAL HEALTH ACT 1983 Section 5(4)
Nurse holding
power.
This means that if a nurse feels that a patient suffers from a mental
disorder and should not leave hospital s/he can complete this form
allowing detention for 6 hours pending being seen by doctor or Approved
Clinician
Section 5(2)
Doctor’s or
Approved
Clinician’s Holding
power
This means that an inpatient is being detained for up to 72 hours by a
doctor or Approved Clinician if appears to suffer from mental disorder and
patient wishes to leave hospital.
Section 4
Admission for
assessment in
cases of
emergency
Individual in detained for up to 72 hours if Doctor believes person is
suffering from mental disorder and seeking another Doctor will delay
admission in an emergency.
( 1 Medical Recommendation and AMHP assessment required)
Section 2
Admission for
assessment
Individual is detained in hospital for up to 28 days for assessment of
mental health.
Criteria:
Suffering from mental disorder of a nature or degree which
warrants the detention of the patient in hospital for assessment
And it is necessary that patient ought to be detained in the
interests of own health, own safety, protection of other persons
(2 Medical recommendations and AMHP assessment required)
Section 3
Admission for
Treatment
Individual is detained in hospital for up to 6 months for treatment of
mental disorder.
Criteria:
Suffering from mental disorder of a nature or degree which makes
it appropriate for patient to receive medical treatment in hospital
And it is necessary for the patient’s own heath, safety, protection
of other persons that patient receive treatment in hospital
(2 Medical recommendations and AMHP assessment required)
Section 7
Guardianship
Individual who suffers from mental disorder can be given a guardian to
help them in the community. Guardianship run for six months and can be
renewable.
Criteria:
Live in a particular place
Attend for medical treatment, occupational; education or training at
set places and at set times.
Allow a doctor, an approved mental health professional or other
named person to see patient
(2 Medical recommendations and AMHP assessment required)
Section 37
Guardianship by
Court Order
Court can make an order (6 months) that patient be given a guardian if
needed because of mental disorder.
The guardian is someone from social services.
Criteria:
Live in particular place
Attend for medical treatment, occupational education or training at
set places and times
Allow a doctor or an approved mental health professional or other
named person to see you
(Court Order required)
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Section 37/4
Admission to
hospital by a
Court Order with
restrictions
Individual admitted to hospital on the order of the Court. This means that
the Court on the advise of two doctors thinks that patient has mental
disorder and need to be in hospital for treatment. Restrictions are made
by the Court and as such patient cannot leave hospital or be transferred
without the Secretary of state for Justice agreement.
(Court Order with restrictions required)
Section 135
Admission of
patients removed
by Police under a
Court Warrant
Individual brought to hospital by a Police Officer on a warrant from Justice
Of Peace which means that an AMHP feels that individual is suffering from
mental disorder for which s/he must be in hospital. Warrant last for 72
hours.
(Section 135 (1){non-detained patient} warrant required or Section
135 (2){ sections and CTO patients} required)
Section 136
Admission of
mentally
disordered
persons found in a
public place
Individual brought to hospital by Police Officer if found in public place and
appears to suffer from mental disorder.
Assessment by Section 12 Approved Doctor and Approved Mental Health
Professional. Section 136 last for 72 hours.
(Police Force Section 136 monitoring form required)
Section 17 A
Community
Treatment Order
(CTO)
CTO allows patients to be treated in the community rather than detention
in hospital. Order last 6 months and is renewable. There are conditions
attached which are:
Be available to be examined by Responsible Clinician for review of
CTO and whether should be extended.
Be available to meet with Second Opinion Doctor or Responsible
Clinician for the purpose of certificate authorising treatment to be
issued.
The Responsible Clinician may also set other conditions if relevant to
individuals, carers and/or family.
(CTO Form to be completed by Responsible Clinician and AMHP)
Section 17 leave Allows Responsible Clinician (RC) to grant day and/or overnight leave of
absence from hospital to patient liable to be detained under the Mental
Health Act 1983.Leave can have set of conditions attached for the
patient’s protection as well as protection of others. Leave can be limited to
specific occasions or longer-term. There is a requirement for RC to
consider CTO if overnight leave will be over 7 days.
(Section 17 leave non-statutory form required)
Section 117
aftercare
This section applies to persons who are detained under Section, 37, 45 A,
transferred direction under section 47 or 48 and who cease to be detained
after leaving hospital. It is the duty of the Health Board and Local
Authorities to provide aftercare under Section 117 free of charge to
patients subject to the above sections. Patients can be discharged from
Section 117 aftercare if they no longer receiving services.
3.1 Mental Health Act - Quarterly Activity Statistical Report
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OFFICIAL
CWM TAF UNIVERSITY HEALTH BOARD MENTAL HEALTH ACT MONITORING COMMITTEE MEETING 15 JUNE 2017
OFFICIAL
Page 1 of 2 AUTHOR TO INSERT GPMS CLASSIFICATION
SUBJECT MENTAL HEALTH REVIEW
GPMS CLASSIFICATION OFFICIAL
REPORT BY PETER THOMAS FORCE ADVISOR ON MENTAL HEALTH
CONTACT OFFICER SUPERINTENDENT ALUN MORGAN
SUMMARY AND PURPOSE OF REPORT Briefing Report for The Mental Health for Cwm Taf University Health Board
RECOMMENDATIONS None
Sir,
I refer to the Mental Health Act Monitoring Committee meeting for Cwm Taf University Health Board on 16th February 2017 and report on the following matters-Crisis Care Concordat, Caswell MOU, The Police and Crime Act 2017, Restraint MOU and Mind Blue Light Programme Wales Concordat On the 23rd May 2017 the steering group met for the first time (21 members) under the chair of James Thomas. Helen Bennett accepted the nomination of chair of the triage/liaison group. The first scheduled meetings for the work streams will commence within 4 weeks of the 23rd May 17. The following are the chairs of the work streams:
Training –James Thomas- AMHP and training officer for Swansea City Social
Services.
Adverse Incident Reporting and Transport- Insp Emma Tyler PSC.
HPOS- Phil Lewis –Director of Nursing CTUHB.
Alternative PoS- Lianne Martyinski, Hafal.
Triage- Helen Bennett
3.2 Mental Health Crisis Care Concordat
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OFFICIAL
AUTHOR TO INSERT MEETING TITLE
OFFICIAL
Page 2 of 2
AUTHOR TO INSERT GPMS CLASSIFICATION
Caswell MOU on Murder/Manslaughter or Attempts
On Friday 19th May 2017 members of the task and finish group met to agree the
final draft of the MOU. The draft will be circulated via the members of the Mental
health Criminal Justice Planning Forum for feedback and sent to Chief
Executives and Assistant Chief Constable Drake for sign off.
Police and Crime Act 2017
On the 3rd May 2017 Chis Witt, Head of Health and Policing at the Home Office
indicated that the earliest timeframe for possible commencement of PACT 2017
will be July 17.
Restraint MOU
A standard operating procedure has been developed from the main document
launched on the 26th January 2017.This is with Dr Gaynor Jones, Chair of the
Mental health Criminal Justice Planning Forum for proof reading before
dissemination.
Mind Blue Light Programme Wales for Emergency Services On 4th May 2017 Keith Bowman from the South Wales Police training department met with Penny Cram from MIND Cyrmu to discuss Blue Light training for police officers and police staff. The training is broken down into 4 areas: 1. Managing for supervisors ( ½ day) 2.Champions Speaking Up/Speaking Out 3.Peer Support 4.Mindfulness,Wellbeing & Resilience (long term) (1/2 Day) The authorization for the training has been approved and the training programme is for first and second line supervisors to identify any signs of mental illness in South Wales Police employees. Training is anticipated to commence in July/August 2017. I attach S136 figures for 2016/17. There has been a small reduction of 4% in detentions compared to 2015/16. I ask that this positional briefing paper be forwarded to Donna Mead, the chair of the Mental Health Act Monitoring Committee for Cwm Taf University Health Board.
Peter Thomas Force Advisor on Mental Health
3.2 Mental Health Crisis Care Concordat
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Mental Health Act Breaches / Analysis of unlawful detention
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AGENDA ITEM 3.3
15 June 2017
Mental Health Act Monitoring Committee Report
BREACHES OF THE MENTAL HEALTH ACT
JANUARY 2017 – MARCH 2017
Executive Lead: Mr John Palmer, Director of Primary Care, Community and Mental Health
Author: Dr Paul D Davies, Assistant Director of Operations (Mental Health) and Mental Health Act Administration team
Contact Details for further information: [email protected]
Tel 01443 443700
Purpose of the Mental Health Act Monitoring Committee Report
A report of Mental Health Act breaches to the Mental Health Act Monitoring
Committee from Quarter 4 (January 2017 - March 2017).
Governance
Link to Health Board Strategic
Objective(s)
The Board’s overarching role is to ensure its Strategy outlined within ‘Cwm Taf Cares’ 3 Year Integrated
Medium Term Plan 2015-2018 and the related organisational objectives aligned with the Institute of
Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:
To improve quality, safety and patient experience.
To protect and improve population health. To ensure that the services provided are
accessible and sustainable into the future. To provide strong governance and assurance.
To ensure good value based care and treatment for our patients in line with the resources made
available to the Health Board.
This report focuses mainly on providing strong governance and assurance.
Supporting evidence
Performance data Glossary of terms of breaches under the Act included
at page 3.
Engagement – Who has been involved in this work?
Staff in the Mental Health Directorate
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Mental Health Act Monitoring Committee Resolution To;
APPROVE ENDORSE DISCUSS √ NOTE √
Recommendation The Mental Health Act Monitoring Committee is requested to:
DISCUSS and NOTE the report.
Summarise the Impact of the Mental Health Act Committee Report
Equality and diversity
No specific equality and diversity issues have been identified.
Legal implications This report presents the local implementation trend of the MHA in terms of breaches.
Population Health No specific impact.
Quality, Safety &
Patient Experience
It is necessary to ensure there is no adverse use
of the MHA sections with Cwm Taf UHB
Resources The report is produced quarterly for the Adult
Mental Health MHA Operational group
Risks and Assurance The report does not present any overt risks
Health & Care Standards
The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:
Staying Healthy
Safe Care Effective Care
Dignified Care Timely Care
Individual Care Staff & Resources
http://www.wales.nhs.uk/sitesplus/documents/1
064/24729_Health%20Standards%20Framework_2015_E1.pdf
The work reported in this summary takes into
account many of the related quality themes Safe Care
Dignified Care
Workforce None
Freedom of information status
Open
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BREACHES OF THE MENTAL HEALTH ACT JANUARY 2017 – MARCH 2017
1. SITUATION / PURPOSE OF REPORT
The purpose of this report is to present activity data regarding the application of the Mental Health Act (1983) and breaches in procedures. The report covers
both Adult and CAMHS services managed by Cwm Taf University Health Board.
2. BACKGROUND
Activity is regularly monitored in the operational Mental Health Committee
chaired by Senior Nurse Samantha Shore, supported by the Mental Health Act administration office and reporting to the Assistant Director of Operations and
the monthly Mental Health Clinical Governance Committee.
3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
Members will be aware of the Categories of Breaches of the Mental Health Act:
Category 1 Administration Breaches within 14 days
The MHA administration office quality assures all MHA paperwork accompanying applications under the Act. All paperwork must be submitted to the MHA
administration office as soon as conveniently possible following any application of the act; for example, following an admission for assessment Section 2. A
breach could be simply an unsigned box or incorrect date, but nevertheless important for compliance. If these are quality assured and corrected within 14
days, there is no technical breach.
Category 2 Incorrect applications of the Act but corrected within 14 days
Such breaches are where the Act has been incorrectly applied but has been
picked up by the MHA administration office and corrected.
Category 3 Incorrect applications of the Act but not corrected
within 14 days
Such breaches are where the Act has been incorrectly applied and not been picked up by the MHA administration office in time. This can be corrected later
but technically it is an illegal detention or treatment.
Category 4 Incorrect applications of the Act and not corrected
Such breaches are where the Act has been incorrectly applied and has not been picked up by the MHA Administration office in time. Legal advice must be
sought to establish legality and next step forward which may be potential harm to patient and legal challenge.
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SUMMARY TABLE (JANUARY TO MARCH 2017)
ADULT MENTAL HEALTH
Category Q4
(Jan to March 2017)
Q3
(Oct to Dec 2016)
1 17 17
2 3 2
3 0 0
4 0 1
Resolved Amended within the 14 days time
limit
Other
17 17
Unresolved 3 3
CAMHS
Category Q4 (Jan to March 2017)
Q3 (Oct to Dec 2016)
1 1 0
2 0 0
3 0 0
4 0 0
Resolved Amended within the 14 days time
limit
Other
1 0
Unresolved 0
Members will be aware that the MHA Team is liaising with professionals to avoid such minor errors in Category 1 and regularly report to the operational Mental
Health Act Monitoring Meeting and to the Clinical Director.
The MHA Team Leader also shares data with the counterpart within MHA
Administration and also ensure that breaches relating to Cwm Taf patients placed within other Health Board are also cascaded.
Members should note that it is only recently that Category 1 and 2 breaches
have been reported under Datix and thus only serious breaches such as Category 4 normally come to the attention of Senior Management.
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Mitigating Actions
All Datix reported incidents are investigated and lessons learnt taken into
the service
The consistent theme of simple errors made by medical staff on the application forms will be taken forward by the Clinical Director as an
action for improvement with medical professional staff
Category 4 Breaches - Incorrect application of the Act
The majority of errors relate to the recording of patient’s personal details and medical recommendations which are reported to the Clinical Director. Each case
is reviewed in detail. Grade 4 breaches are low, however specific training in areas has been offered to avoid invalid detentions.
4. RECOMMENDATION
The Mental Health Act Monitoring Committee is requested to:
DISCUSS and NOTE the report.
Freedom of
information status
Open
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All Wales Mental Health Act Benchmarking Report
April 2017
Executive Lead: Chief Operating Officer
Author: Head of Operations and Delivery – Mental Health
Financial impact - NA
Quality, Safety, Patient Experience impact -
Healthcare Standard Number 1 and 6 CRAF Reference Number – 8.1.2
Equality Impact Assessment Completed: Not Applicable
RECOMMENDATION The Board/Committee is asked to:
Agree the approach taken by the Mental Health Clinical Board
SITUATION The Welsh Health Board’s responsibilities as Hospital Managers are to ensure compliance with the Mental Health Act. This is formally delegated to UHB staff, particularly mental health staff and mental health act administration departments as per the Hospital Managers' Scheme of Delegation. The Hospital Managers must ensure that patients are detained only as the Act allows, that their treatment and care fully comply with it, and that patients are fully informed of, and supported in exercising, their statutory rights. Hospital Managers must also ensure that a patient’s case is dealt with in line with other legislation which may have an impact. Within this responsibility this paper recaps on how Cardiff and Vale MHCB has explored, made recommendations and has now collated benchmark information in relation to additional measures to provide Health Board Mental Health Legislation Committees with assurance in three specific areas:
1. Invalid detentions under the Mental Health Act - With a proposal that they are all:
consistently reported to allow for monitoring, investigation and improvements,
reported to a standardized definition to allow for comparison and performance management,
investigated to a minimal standard with a standard response to repeated breeches to allow for consistency and fairness of approach.
The overall aim is to have zero invalid detentions.
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2. A Common Data Set of mental health act activity and compliance – With a proposal of an All
Wales agreement for critical mental health act activity relevant to current service changes to inform management decisions with the aim of sharing this information on a regular basis to allow for benchmarking and improvements to be planned.
3. Errors protocol - a proposed protocol for responding to professionals who make repeated mistakes I relation to the application of the Mental Health Act.
BACKGROUND The Cardiff and Vale General Manager led an initial working group of Mental Health Act Administrator Representatives of C&V, Hywel Dda, Aneurin Bevan and Cwm Taf Health Boards. This was followed by attendance at the all-Wales mental health act administrators meeting for October 2016, where this document was presented on behalf of the UHBs at the initial working group. All UHBs in Wales represented at this meeting. At this meeting agreement was established for the rationale for the data collection but not all UHBs were able to commit to the extent of data collection described in this paper. It was further agreed to circulate an electronic copy of the report for individual UHB mental health act administrators offices to assess their ability to contribute to this routine bi annual data collection exercise with the support of their line managers and/or clinical governance leads. It was suggested and agreed that the core mental health act data collected would initially reflect the collation capacity of the majority of UHBs. This information was copied to mental health service leads for information and support. Cardiff and Vale UHB offered to collate this information from January ‘17 on behalf of the Welsh UHBs and circulate to all UHBs regardless of their ability to collect it to allow for information and ideas exchange. Areas of agreement Reached: 1. Agreed Invalid Detentions Definition The experience of the Health Boards consulted with, were that they are reporting a number of invalid detentions on a regular basis whereby patients have been detained without authority for a number of reasons reported to their Legislation Committees. Some of these incidents have resulted in detention for a number of hours to a number of days/weeks due to procedures not being followed mainly in relation to receipt of an application for admission for assessment or treatment. The information gathered from an analysis of these incidents suggests that reporting could be simplified into two categories in relation to a definition and level of seriousness as follows:
Rectifiable Errors – concerned with errors resulting from inaccurate recording – invalid detention which can be retrospectively validated
Fundamentally Defective Errors – concerned with errors other than the above.
Definition - These two categories were chosen with reference to the Code of Practice (Ch10.15) which states any rectification, or correction, is mainly concerned with inaccurate recording, and it cannot be used to enable a fundamentally defective application to be retrospectively validated. Rectifying or correcting cannot be used to cure a defect which arises because an element of the procedural process leading to the detention has simply not taken place at all. Therefore a form may be ‘incorrect‘, for example, if names, dates or places are mis-stated, but which, if corrected, would not make the decision to admit a patient an unjustified one, and it may be ‘defective’ if the signatory has failed to complete all the sections, or delete alternative options. An unsigned form should not be accepted as rectifiable.
3.5 National Approach to Mental Health Act Breaches
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In terms of investigation and reporting of invalid detentions, rectifiable or not, the minimum standard suggested by the working group was to ensure an incident report was completed and a summary provided to the local MHLC at each meet containing:
Numbers
Short description of breech identifying cause
Summary of follow up actions taken to mitigate future risk.
The individual UHBs to discuss implementation of these minimum standards with line managers and Q&S departments. 2. Agreed Common Data Set (See Assessment Section) UHB agreement arrived at WAS to collate a minimum data set, easy to collect, currently available for the majority of UHBs, had existing definitions and would be useful to share. The following more specific reasons for collating core data were:
General Mental Health Act Activity – activity data which reflected the volume of use of the act and therefore could support further questions related to acuity, bed availability, community services capacity etc. With 135/6 data to gauge response to the police concordat and collaboration with partners responding to people in crisis. Useful to subdivide into gender age and speciality to monitor demand and equality.
Rectifiable and fundamentally defective errors – see rationale above in this paper
3. Agreed Errors Protocol Standard Agreement reached to adopt a common approach again to support consistency of application, response and ultimately to support the reduction or absence of people detained unlawfully. ASSESSMENT (See Attached)
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1
ASSESSMENT
Benchmarking data October - December 2016:
Cardiff and Vale UHB Hywel Dda HB Cwm Taf HB ABMU UHB
For the purposes of the report, until the process can assure greater
confidence and completeness of data, the activity has been anonymised
3.5.1. Appendix 1
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Part 2 (Inpatient) MHA Activity
During the period a total of 672 patients were subject to the part 2 provisions of the MHA 1983 across
the four HB’s who provided the data to collate this report.
Adult Acute Older People
0
20
40
60
80
100
120
140
160
180
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Adult Acute Older People CAMHS LD General
Section 5(2)
Section 5(4)
Section 4
Section 3
Section 2
0
20
40
60
80
100
120
140
160
180
1 2 3 4
Adult Acute
Section 5(2)
Section 5(4)
Section 4
Section 3
Section 20
5
10
15
20
25
30
35
40
1 2 3 4
Older People
Section 5(2)
Section 5(4)
Section 4
Section 3
Section 2
3.5.1. Appendix 1
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CAMHS General
LD
Comments
Wide variation in adult services of use of MH Act
Incomplete data for CAMHS
Opportunity for UHBs to review emergency assessment pathways
0
1
2
3
4
5
6
1 2 3 4
CAMHS
Section 5(2)
Section 5(4)
Section 4
Section 3
Section 2
02468
10121416
1 2 3 4
General
Section 5(2)
Section 5(4)
Section 4
Section 3
Section 2
216, 32%
175, 26%
118, 18%
163, 24%
Total (2,3,4,5(4) & 5(2))
1
2
3
4
0
2
4
6
8
10
12
14
1 2 3 4
LD
Section 5(2)
Section 5(4)
Section 4
Section 3
Section 2
3.5.1. Appendix 1
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Section 135 & 136
The charts below provide data on how section 135/136 is used across the four HB’s broken down into
specialities, HB’s and total activity across the HB’s.
Comments
Police concordat proving effective with only 1 UHB assessing in custody
Learn from UHB 3 to reduce overall 136 numbers – useful to develop bench mark average
0
10
20
30
40
50
60
70
80
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Adult Acute Older People CAMHS LD General
Section 136 (Custody)
Section 136(Hospital)
Section 135
0
10
20
30
40
50
60
70
80
1 2 3 4
Section 136(Custody)
Section136(Hospital)
Section 135
4, 45%
3, 33%
1, 11%
1, 11%
Section 135
1
2
3
4
63, 29%
58, 26% 34, 15%
67, 30%
Section 136(Hospital)
1
2
3
4
Section 136 (Custody)
1
2
3
4
3.5.1. Appendix 1
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Rectifiable Errors
Rectifiable errors by HB and speciality.
Total Number of rectifiable errors per HB.
Total number of rectifiable errors across the four HB’s.
Comments
Possible reporting issue in UHB 4
Wide UHB variation across age groups in all UHBs to help with clinical governace
investigation
Case for consistency with the investigation and approach to rectifiable errors – opportunity for
exchange of training information
Help to support with parameters after further data points collected
0
10
20
30
40
50
60
70
80
Adult Acute Older People CAMHS LD General
1
2
3
4
0
20
40
60
80
100
120
140
1 2 3 4
40, 17%
79, 33% 118, 49%
3, 1%
1
2
3
4
3.5.1. Appendix 1
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Fundamentally Defective
Number of fundamentally defective applications by speciality and HB.
Total number of fundamentally defective applications per HB
There were a total of 11 fundamentally defective applications across the four HB’s.
0
0.5
1
1.5
2
2.5
3
3.5
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Adult Acute Older People CAMHS LD General
Section 5(2)
Section 5(4)
Section 4
Section 3
Section 2
0
1
2
3
4
5
6
7
1 2 3 4
Section 5(2)
Section 5(4)
Section 4
Section 3
Section 2
4, 36%
6, 55%
0%
1, 9%
1
2
3
4
3.5.1. Appendix 1
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Comments
Incomplete data UHB 3
Issues for training in the DGH
Low numbers across UHBs
Hospital Managers Activity
Hospital managers’ hearings arranged during the period by speciality and HB.
Total number of hearings arranged by HB.
A total of 167 managers hearings were arranged across the four HB’s.
0
10
20
30
40
50
60
70
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Adult Acute Older People CAMHS LD General
Discharged by HM's
Review of Papers
Barring Hearings
Renewal Hearings
Application by patient
0
10
20
30
40
50
60
70
1 2 3 4
Review of Papers
Barring Hearings
Renewal Hearings
Application bypatient
3.5.1. Appendix 1
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Hospital Managers across the all HB’s did not exercise their power of discharge during the period.
MHRT Activity
Total numbers of Tribunals arranged during the period.
A total of 223 tribunal hearings were arranged across the four HB’s.
59, 35%
55, 33%
35, 21%
18, 11%
1
2
3
4
0
10
20
30
40
50
60
70
80
90
1 2 3 4
Referral by Welsh Ministers
Referral by MOJ
Referral on behalf of HM's
Application by patient
81, 36%
61, 27%
35, 16%
46, 21% 1
2
3
4
0
1
2
3
4
5
1 2 3 4
Discharged by MHRT
1
2
3
4
3.5.1. Appendix 1
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Mental Health Act (1983) section 117 - Aftercare
Internal Audit Report
2016/17
Cwm Taf University Health Board
Private and Confidential
NHS Wales Shared Services Partnership
Audit and Assurance Service
4.1 Internal Audit Report on Mental Health Act S117 for review and monitoring from Audit Committee
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Mental Health Act (1983) section 117- Aftercare Report Contents
Cwm Taf University Health Board
NHS Wales Audit & Assurance Services Page | 2
CONTENTS Page
1. Introduction and Background 3
2. Scope and Objectives 3
3. Associated Risks 4
Opinion and key findings
4. Overall Assurance Opinion 5
5. Assurance Summary 6
6. Summary of Audit Findings 7
7. Summary of Recommendations 9
Review reference: CTU1617.12
Report status: Final Fieldwork commencement: 9 January 2017
Fieldwork completion: 8 February 2017
Clearance meeting: 27 February 2017
Draft report issued: Management response received:
28 February 2017 14 March 2017
Final report issued: 16 March 2017
Auditors: Ian Virgill, Lucy Jugessur
Executive sign off: John Palmer, Director of Primary, Community
& Mental Health
Distribution: Paul Davies, Assistant Director of Operations
Pamela Connor, Team Leader
Debra Pennell, Directorate Support Manager
Committee: Audit Committee
ACKNOWLEDGEMENT
NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this review.
Please note:
This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.
Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance Services, and addressed to Independent Members or officers including those designated as Accountable Officer. They are prepared for the sole use of Cwm Taf University Health Board and no responsibility is taken by the Audit and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third party.
Appendix A Appendix B
Management Action Plan Assurance opinion and action plan risk rating
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Mental Health Act (1983) section 117 - Aftercare Internal Audit Report
Cwm Taf University Health Board
NHS Wales Audit & Assurance Services Page | 3
1. Introduction and Background
Our review of the management of Mental Health Act (1983) section 117 - aftercare procedures was completed in line with the 2016/17 Internal
Audit Plan for Cwm Taf University Health Board (the ‘Health Board’).
The relevant lead Executive Director for the review is the Director of
Primary, Community & Mental Health.
Section 117 of the Mental Health Act (1983) (the ‘Act’) provides a legal
right to aftercare services for anyone who has been detained under the following sections of the Act:
Section 3 – admission to a hospital for treatment;
Section 17A – release of a detained patient, subject to a Supervised
Community Treatment order;
Section 37/41 – power of courts to order hospital admission or
guardianship;
Section 45A – power of higher courts to direct hospital admission;
Section 47 – removal to hospital of persons serving sentences of
imprisonment; and
Section 48 – removal to hospital of other prisoners when they cease to
be detained and leave hospital.
The duty to provide aftercare services under section 117 applies when a
patient ceases to be detained and leaves hospital. The duty also applies to detained patients on periods of Section 17 leave.
The Act places an enforceable joint duty upon the Health Board and the local Social Services Authority, in co-operation with any relevant voluntary
organisation, to provide aftercare services for certain categories of mentally disordered patients who have ceased to be detained in hospital
or prison if they have spent part of their sentence detained in hospital.
Aftercare services under section 117 can include almost anything that
helps the patient to live in the community, such as help with accommodation, social care support, or day centre facilities. The purpose
of providing free aftercare is to try to prevent an individual’s condition
deteriorating to a point where they need to be readmitted to hospital.
2. Scope and Objectives
The objective of our audit was to evaluate and determine the adequacy of the systems and controls in place for the management of section 117
arrangements, in order to provide assurance to the Health Board’s Audit Committee that risks material to the achievement of the system’s
objectives are managed appropriately.
The purpose of this review was to provide assurance to the Audit
Committee that the Health Board has adequate procedures in place to
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ensure that all relevant patients are appropriately assessed in order to
establish their eligibility for free aftercare services and all eligible patients receive appropriate services.
The main areas that the review sought to provide assurance on were:
there is a formally documented policy and procedure in place for the
management of section 117 arrangements;
the Health Board maintains an accurate register of all patients who
are subject to section 117 aftercare;
patients subject to section 117 are appropriately assessed before
being discharged from hospital;
a care plan, stating the services to be provided, is produced for
patients who are identified as being eligible for aftercare;
eligible patients actually receive the aftercare services that have been
identified;
on-going regular reviews of patient’s requirements for aftercare are
carried out in conjunction with Social Services;
an appropriate reassessment of need is carried out before section 117 services are removed from any patient and appropriate reasons
for the removal of services are identified and recorded; and
periodic reports on the management of section 117 are produced
and submitted to management and Health Board groups for appropriate review and action.
3. Associated Risks
The potential risks considered in the review were:
patients who are eligible for section 117 aftercare are not identified;
eligible patients do not receive appropriate aftercare; and
patients continue to receive aftercare when it is no longer required.
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OPINION AND KEY FINDINGS
4. Overall Assurance Opinion
We are required to provide an opinion as to the adequacy and
effectiveness of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives
within this report. An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the
identified risks associated with the objectives covered in this review.
The level of assurance given as to the effectiveness of the system of
internal control in place to manage the risks associated with the management of the Mental Health Act (1983) section 117 - Aftercare is
Reasonable Assurance
Reason
ab
le
assu
ran
ce
- +
Yellow
The Board can take reasonable assurance that arrangements to secure
governance, risk management and internal control, within those areas under review, are suitably designed and applied
effectively. Some matters require management attention in control design or
compliance with low to moderate impact on residual risk exposure until resolved.
There were a number of issues identified with the management of Mental Health Act (1983) section 117 – Aftercare.
The policy for the implementation of the Act confirms the processes that need to be followed with regards to section 117 patients. However, there
were instances whereby the policy was not being complied with as initial meetings were not held within two – four weeks of the section application.
In addition, the policy confirms the documentation that should be completed for these meetings and the correct paperwork was not always
completed.
‘Termination of Aftercare’ forms are not always being sent to the central mental health office for the Mental Health Act administrator to update the
section 117 register. In addition, one form was not signed by the responsible clinician within the Health Board as authorisation to remove
section 117 aftercare from the patient.
Section 117 meetings are held regarding the administration processes but
the minutes are not being reported to any Health Board Groups.
The overall level of assurance that can be assigned to a review is
dependent on the severity of the findings as applied against the specific review objectives and should therefore be considered in that context.
More detailed findings can be found within section 6 of this report under: Summary of Audit Findings and the Action Plan, at Appendix A.
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5. Assurance Summary
The summary of assurance given against the individual objectives is described in the table below:
Assurance Summary
1
There is a formally
documented policy and procedure in place for section 117
2 The Health Board maintains an accurate register of all
section 117 patients
3
Patients subject to section
117 are appropriately assessed before being discharged from hospital
4
A care plan is produced for patients who are identified
as being eligible for aftercare
5
Eligible patients actually receive the aftercare
services that have been identified
6 On-going regular reviews of patient’s requirements for aftercare are carried out
7
An appropriate reassessment of need is
carried out before section 117 services are removed
8
Periodic reports on the management of section
117 are produced and submitted to management and Health Board groups
* The above ratings are not necessarily given equal weighting when generating the audit
opinion.
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Design of Systems/Controls
The findings from our review have highlighted one issue that is classified as a weakness in the system control/design for the management of Mental
Health Act section 117 - Aftercare.
Operation of System/Controls
The findings from our review have highlighted six issues that are classified as weakness in the operation of the designed system/control for the
management of Mental Health Act section 117 - Aftercare.
6. Summary of Audit Findings
Objective 1: There is a formally documented policy and procedure in place for the management of section 117 arrangements
We identified the following good practice:
The Health Board has produced a policy for the implementation of
section 117 of the Mental Health Act in collaboration with Merthyr Tydfil County Borough Council and Rhondda Cynon Taf. The policy was
approved in May 2014 and is due to be reviewed in May 2017.
We identified the following significant finding under this objective:
There have been some amendments to the Act and therefore the
policy for the implementation of section 117 of the Mental Health Act is out of date and needs revising.
Objective 2: The Health Board maintains an accurate register of all patients who are subject to section 117 aftercare
We identified the following area of good practice:
The Mental Health Act administrator maintains a database of all
mental health patients which records the section they are subject to and also if they are subject to section 117 aftercare.
We did not identify any significant findings under this objective.
Objective 3: Patients subject to section 117 are appropriately
assessed before being discharged from hospital
We identified the following significant findings under this objective:
4/20 sampled section 117 patients did not have an initial meeting
within two - four weeks of the section application being made, which is not in accordance with the policy for the Implementation of section
117 of the Mental Health Act.
We identified 12 cases where incorrect documentation was used in the
initial meetings.
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Objective 4: A care plan, stating the services to be provided, is
produced for patients who are identified as being eligible for aftercare
We identified the following area of good practice:
Our testing confirmed that care plans are produced for the patients
whilst they are in hospital and they are reviewed throughout the patients stay.
We identified the following significant finding under this objective:
From the sample of 20 patients reviewed, two had no documentation
held on the electronic shared drive.
Objective 5: Eligible patients actually receive the aftercare
services that have been identified
We identified the following significant findings under this objective:
Following discharge from hospital, the Swift database is utilised by the Community Mental Health Teams (CMHTs) to record all patients that
are under section 117. From the sample of 12 patients reviewed, there
were 2 that were not recorded on the Swift database as section 117 patients.
We checked the care plans for a sample of patients to confirm that aftercare was being provided as detailed in the care plans. One patient
had passed away on the 5 November 2016 but records had not been updated and the patient was still on the Swift system.
Objective 6: On-going regular reviews of patient’s requirements for aftercare are carried out in conjunction with Social Services
We identified the following area of good practice:
We reviewed the patients that had been discharged into the
community to confirm that regular reviews were undertaken with them. It was evident from the patient’s records that the Care
Coordinators visit the patients more often than stipulated in the policy. Furthermore, the Care and Treatment plan review paperwork
was updated where required and this was evidenced with the copies of
the documentation held on the patient’s files.
We did not identify any significant findings under this objective.
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Objective 7: An appropriate reassessment of need is carried out
before section 117 services are removed from any patient and appropriate reasons for the removal of services are identified and
recorded
We identified the following area of good practice:
Patients are only removed from section 117 services if it is considered that they no longer require secondary services. Reassessments are
undertaken prior to the patients being removed from the section 117 database.
We identified the following significant finding under this objective:
Our review of six ‘Termination of Aftercare’ forms identified that one
had not been signed by the responsible clinician on behalf of the Health Board. In addition, two forms had not been sent to the Mental
Health Act administrator to record in the section 117 register.
Objective 8: Periodic reports on the management of section 117
are produced and submitted to management and Health Board
groups for appropriate review and action
We identified the following area of good practice:
A section 117 meeting is held which is an administration meeting where administration processes are reviewed and any queries that
administration team leaders may have are reviewed within this forum.
We identified the following significant finding under this objective:
The section 117 meeting minutes are not reported to any other forum such as the Clinical Governance Board or Board and no other reports
on the management of section 117 requirements are produced.
7. Summary of Recommendations
Our audit findings and recommendations are detailed in Appendix A together with the management action plan and implementation timetable.
A summary of these recommendations by priority is outlined below.
Priority H M L Total
Number of recommendations
1 5 1 7
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Finding 1 – Initial meeting following section application (Operational) Risk
The policy for the implementation of section 117 of the Mental Health Act
identifies that an initial meeting should be held with the patient within two – four weeks of the section application.
We tested a sample of twenty patients and note that four did not have an initial meeting undertaken within the required two – four weeks of the section
application being made. Of the four patients identified:
Two patients’ initial meetings were undertaken five weeks after the
section application was made.
One patient’s initial meeting was seven weeks after the section application was made.
One patient’s initial meeting was 15 weeks after the section application was made.
For the sample of patients we also checked that the correct Mental Health Measure (MHM) Care and Treatment Planning form was completed for the initial
meeting, in line with the policy for implementation of section 117 of the Mental Health Act. We noted 12/20 instances where the MHM Care and Treatment
Planning form wasn’t completed but a Care and Treatment Plan (CTP) form was completed instead. This is the form that should be utilised to ensure that
regular planned reviews take place.
Eligible patients do not receive
appropriate aftercare.
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Recommendation 1 Priority level
Management should ensure that the policy for the implementation of section
117 of the Mental Health Act is complied with and initial meetings are held
within two - four weeks of the section application.
Management should ensure that the Care Treatment Plan review form should
be completed for the initial meetings as per the Policy for Implementation of Section 117 of the Mental Health Act.
High
Management Response 1 Responsible Officer/ Deadline
Initial Meeting between 2-4 weeks – As per Cwm Taff CTUHB policy should be
implemented into practice.
Reminder to all Consultant and Team Managers to reinforce good practice that
all initial meetings take place within 4 weeks.
Reminder to be sent to all Consultants and Team Managers to reinforce the use
of the CTP/S117 Review form for all S117 reviews that take place. A Copy of the required CTP/S117 Review Form will be attached to e-mail.
Lynne Garwood – 6.3.17 (sent)
Lynne Garwood – 6.3.17 (sent)
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Finding 2 – Policy for Implementation of Section 117 of the Mental Health Act
(Design) Risk
The policy for the implementation of section 117 of the Mental Health Act was agreed and approved on the 21 May 2014 and is due to be reviewed in May
2017.
However, we note that there have been some amendments to the Act,
including the process to be followed upon the death of a section 117 patient,
and therefore the current policy is already out of date and requires revising to be in line with the Mental Health Act.
Eligible patients do not receive appropriate aftercare.
Recommendation 2 Priority level
Management should review and update the policy for the implementation of
section 117 of the Mental Health Act in line with the changes with the Mental Health Act.
Medium
Management Response 2 Responsible Officer/ Deadline
S117 Policy is currently under review and has included all amendments under the most recent Mental Health Code of Practice. This Policy will need to be
ratified via the Policies and Procedures Group and then taken through Clinical Governance for final ratification.
Lynne Garwood on behalf of the Mental Health Directorate –
Policy updated within 1 month – 6.4.2017
Ratified within 2 months – 6.5.2017
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Finding 3 – Maintenance of documentation (Operational) Risk
Copies of all section 117 patients’ documentation, including the initial assessment and on-going care plans, should be maintained on the Health
Board’s electronic ‘w’ shared drive.
We tested a sample of twenty patients and note that:
for one of the patients sampled there was no care plan in place and there was no other documentation held on the shared drive for the patient; and
a second patient did not have an initial meeting on file and there was no other documentation on the shared drive for the patient.
Eligible patients do not receive appropriate aftercare.
Recommendation 3 Priority level
Management should ensure copies of all paperwork is maintained on the shared drive as evidence that the appropriate meetings are held and that the required
documentation such as care plans are being completed in line with the Policy for Implementation of Section 117 of the Mental Health Act.
Medium
Management Response 3 Responsible Officer/ Deadline
The Mental Health Directorate works with over 3 different IT systems within inpatient and community settings. Local authority does not have direct access
to the health W drive for saving documentation. The number of IT systems in use has already been highlighted as a significant risk on the Directorate’s Risk
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Register.
Reminder to be sent to all health staff ensuring that all patient documentation is uploaded and saved onto the W drive. This is to be done by ensuring admin
team leaders reinforce this within teams and information taken to Community
Mental Health Team Meetings. An e-mail will also be sent to ward managers to ensure that documentation is uploaded and saved onto the W Drive. Local
authority staff will continue to save information to the Swift ESR system.
New Policy will make reference to the new patient information system WCCIS
which will be introduced into community teams over the next 6 months and will be used in the community by health and social services. Inpatient services are
likely to go to WCCIS in 2018.
D Pennell – 17.4.17
Suzanne Claridge – 6.4.17
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Finding 4 – Maintenance of patient records in the Community (Operational) Risk
Following discharge from hospital, section 117 patients should be recorded on
the Swift database within the Community Mental Health Teams (CMHTs). We selected 15 section 117 patients that had been discharged into the community
to check that they were appropriately recorded on the Swift database as section 117 patients. However, our testing identified two patients that were not
recorded on the Swift database as section 117 patients.
In addition, we checked the care plans for the patients and that after care was
being provided as detailed on the care plans. Our testing identified that one
patient had passed away in November 2016 but, at the time of our audit fieldwork in January, CMHT records had not been updated, and as such the
patient was still on the Swift system.
Eligible patients do not receive
appropriate aftercare.
Recommendation 4 Priority level
Management should ensure that all section 117 patients are recorded correctly on the Swift database as section 117 patients.
Management within the Community Mental Health Teams should update their records when a patient has passed away including updating the Swift
database. Furthermore, a Termination of Aftercare form should be completed
and sent to the Mental Health Team so that records can be updated.
Medium
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Management Response 4 Responsible Officer/ Deadline
Reminder sent to all Managers and staff reinforcing the need to forward all
relevant information to Business Support with regard to updates on S117
status. Admin Team Leaders to reinforce this in Community Mental Health Team Meetings
D Pennell – 6.4.17
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Finding 5 – Removal of services for patients (Operational) Risk
The policy for the Implementation of section 117 of the Mental Health Act
confirms that a ‘Termination of Aftercare’ form needs to be completed if a
person no longer requires aftercare. A section 117 review meeting should be carried out to assess the patient that includes a representative from the Local
Authority and the Health Board.
We tested 6 patients in the CMHTs that no longer receive section 117 aftercare
to establish if the appropriate assessment had been undertaken and agreed by a representative from the Local Authority and a responsible clinician from the
Health Board.
Whilst ‘Termination of Aftercare’ forms had been completed for all 6 patients,
one form had not been signed by the responsible clinician on behalf of the Health Board. In addition, two forms had not been sent to the Mental Health
Act Administrator to record in the section 117 database that they no longer require aftercare.
Patients continue to receive
aftercare when it is no longer
required.
Recommendation 5 Priority level
Management need to ensure that all ‘Termination of Aftercare’ forms are signed by appropriate personnel in line with the policy for the Implementation of
section 117 of the Mental Health Act. In addition, the forms should be sent to the Mental Health Act Administrator so that the section 117 database and the
patient records / Myrddin are updated appropriately.
Medium
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Management Response 5 Responsible Officer/ Deadline
A Termination Form is in place and gives clear direction for discharge from
S117.
A reminder with a copy of the Termination of Aftercare Form is to be
recirculated to all Consultants and Team Leaders.
This will also be reinforced through Clinical Governance.
Lynne Garwood – 6.4.17
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Finding 6 – Section 117 meetings (Operational) Risk
The policy for Implementation of Section 117 states that the section 117
process will be monitored for effectiveness by the section 117 steering group,
but we were not provided with any agendas or minutes of the steering group to confirm that monitoring was being carried out.
However, Team Managers and Consultants are given regular reports showing which patients are on section 117.
Furthermore, an ad hoc section 117 meeting is held which is an administration meeting where processes are reviewed and any queries that the Administration
Team Leaders may have are discussed within this forum. However, this meeting does not report upwards into any other health board groups or
committees and no other reports on compliance with section 117 requirements are produced.
Patients continue to receive
aftercare when it is no longer
required.
Recommendation 6 Priority level
The management of section 117 patients should be effectively reported and monitored and the minutes of section 117 meetings should be formally reported
into an appropriate Health Board group or committee for review and action.
Medium
Management Response 6 Responsible Officer/ Deadline
Discussed in Directorate Management Team Meeting on the 28th February 2017. Agreed to reinstate the S117 Steering Group that will report directly back to
the Directorate Management Team Meeting and the Mental Health Act
Lynne Garwood
Debra Pennell – 6.4.17
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Monitoring Group on a quarterly basis. Quarterly reports will also be sent to
Clinical Governance. The Admin S117 meeting will now be incorporated within the S117 Steering Group Meeting.
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Finding 7 – Recording of section 117 patients (Operational) Risk
We selected a sample of 20 patients that were subject to section 117 according
to the database maintained by the Mental Health Act Administrator and reviewed the Myrddin Patient Management System to check that the patients
had been appropriately flagged as being subject to section 117 on Myrddin.
We note that three of the 20 patients reviewed were not recorded as being
subject to section 117 on Myrddin.
Patients who eligible for section 117
aftercare are not identified.
Recommendation 7 Priority level
Management should ensure that patient information recorded on the Myrddin
Patient Management System appropriately reflects their section 117 status. Low
Management Response 7 Responsible Officer/ Deadline
Procedure for recording S117 patients on Myrddin to be developed and audits
will be undertaken.
It has also been agreed that a 6 monthly audit of S117 clients will be developed
and undertaken by the Directorate and fed back accordingly through Audit Committee.
D Pennell 6.4.17
Lynne Garwood – 6.4.17
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Action Plan
NHS Wales Audit & Assurance Services Appendix B
Audit Assurance Ratings
Substantial assurance - The Board can take substantial assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Few matters require
attention and are compliance or advisory in nature with low impact on residual risk
exposure.
Reasonable assurance - The Board can take reasonable assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Some matters require
management attention in control design or compliance with low to moderate impact on
residual risk exposure until resolved.
Limited assurance - The Board can take limited assurance that arrangements
to secure governance, risk management and internal control, within those areas under
review, are suitably designed and applied effectively. More significant matters require
management attention with moderate impact on residual risk exposure until resolved.
No Assurance - The Board has no assurance that arrangements to secure
governance, risk management and internal control, within those areas under review, are
suitably designed and applied effectively. Action is required to address the whole control
framework in this area with high impact on residual risk exposure until resolved
Prioritisation of Recommendations
In order to assist management in using our reports, we categorise our recommendations
according to their level of priority as follows.
* Unless a more appropriate timescale is identified/agreed at the assignment.
Priority
Level
Explanation
Management
action
High
Poor key control design OR widespread non-compliance
with key controls.
PLUS
Significant risk to achievement of a system objective OR
evidence present of material loss, error or misstatement.
Immediate*
Medium
Minor weakness in control design OR limited non-
compliance with established controls.
PLUS
Some risk to achievement of a system objective.
Within One
Month*
Low
Potential to enhance system design to improve efficiency or
effectiveness of controls.
These are generally issues of good practice for
management consideration.
Within
Three
Months*
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Royal College of Psychiatrists Review Follow up
Final Internal Audit Report
2016/17
Cwm Taf University Health Board
Private and Confidential
NHS Wales Shared Services Partnership
Audit and Assurance Service
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Royal College of Psychiatrists Review Follow up Report Contents
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CONTENTS Page
1. Introduction and Background 3
2. Scope and Objectives 3
3. Associated Risks 3
Opinion and key findings
4. Overall Assurance Opinion 4
5. Assurance Summary 5
6. Summary of Audit Findings 6
7. Summary of Recommendations 7
Review reference: CTU1617.13
Report status: Final Fieldwork commencement: 23 November 2016
Fieldwork completion: 10 January 2017
Draft report issued: Draft report clearance meeting:
Management response received:
24 January 2017 30 January 2017
3 February 2017 Final report issued: 3 February 2017
Auditors: Ian Virgill, Liz Vincent
Executive sign off: John Palmer, Director of Primary, Community
& Mental Health
Paul Davies, Assistant Director of Operations
Distribution: Adarsh Shetty, Clinical Director
Philip Lewis, Head of Mental Health Nursing
Committee: Audit Committee
ACKNOWLEDGEMENT
NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this review.
Please note:
This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.
Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance Services, and addressed to Independent Members or officers including those designated as Accountable Officer. They are prepared for the sole use of Cwm Taf University Health Board and no responsibility is taken by the Audit and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third party.
Appendix A Appendix B
Management Action Plan Assurance opinion and action plan risk rating
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1. Introduction and Background
Our review of progress against the Royal College of Psychiatrists (RCP)
report was completed in line with the 2016/17 Internal Audit plan for
Cwm Taf University Health Board (the ‘Health Board’).
In December 2014 the Health Board invited the RCP Invited Review
Service (IRS) to carry out a review of the current model of acute mental health services for adults of working age. The particular matters on which
guidance was sought were:
gate-keeping for the admission of emergency adult patients;
management of sub-specialty patients; and
overall clinical responsibility for patients on an assessment ward.
The IRS’s fieldwork was carried out in April 2015 with a formal report to the Health Board in June 2015. The report included a total of eight specific
recommendations for implementation by the Health Board, and three more general recommendations around the effective operation of the
Admission Unit.
2. Scope and Objectives
The overall objective of our review was to provide the Health Board with
assurance over the actions that have been taken to address the recommendations made in the IRS report.
The scope of our review did not aim to provide assurance against the full scope and objectives of the original IRS review. Our follow up review
opinion provides an assurance level against the implementation of the agreed recommendations only.
The main areas that our review sought to provide assurance on were:
that an appropriate action plan was developed to address the
recommendations from the IRS review;
the action plan was subject to appropriate communication and
approval;
appropriate progress has been made with the implementation of the
agreed actions identified to address the recommendations;
adequate evidence is available to support the level of progress; and
the actions implemented have effectively addressed the
recommendations identified in the IRS report.
3. Associated Risks
The potential risk considered in our review was:
the risks identified in the IRS review that resulted in the agreed
recommendations are not effectively addressed.
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OPINION AND KEY FINDINGS
4. Overall Assurance Opinion
We are required to provide an opinion as to the adequacy and
effectiveness of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives
within this report. An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the
identified risks associated with the objectives covered in this review.
The level of assurance given as to the effectiveness of the system of
internal control in place to manage the risks associated with the findings from the IRS review is Reasonable Assurance.
Reaso
nab
le
assu
ran
ce
- +
yellow
The Board can take reasonable
assurance that arrangements to secure governance, risk management
and internal control, within those areas under review, are suitably
designed and applied effectively. Some matters require management
attention in control design or compliance with low to moderate
impact on residual risk exposure until resolved.
An appropriate action plan was developed by the Directorate to focus on
the recommendations identified in the original IRS Review. The plan included details of the actions required to address the 8 recommendations
and 3 commentaries that were included in the IRS report. Details of the delegated leads and target dates for completion of the actions were also
included on the plan.
The action plan was subject to appropriate approval by the Mental Health Clinical Governance Committee and was communicated to the September
2015 meeting of the Cwm Taf Clinical Governance Committee.
The latest version of the action plan, updated in November 2016 states
that all the agreed actions have been completed and through our discussions with management we were assured that sufficient progress
has been made in addressing the original report findings. However we were unable to obtain evidence to fully verify the stated progress for 4 of
the 8 recommendations.
Our review has confirmed that the completed actions have effectively
addressed the majority of the recommendations from the original IRS report. However there is one action, relating to the consideration of the
staffing levels within the unit, that we are unable to confirm has fully addressed the IRS recommendation.
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The overall level of assurance that can be assigned to a review is dependent on the severity of the findings as applied against the specific
review objectives and should therefore be considered in that context.
Our detailed findings can be found within section 6 of this report and the Action Plan, at Appendix A.
5. Assurance Summary
The summary of assurance given against the individual objectives is
described in the table below.
Assurance Summary
1
An appropriate action plan was developed to address the recommendations from
the IRS review
2
The action plan was subject
to appropriate communication and
approval
3
Appropriate progress has
been made with the implementation of the agreed actions identified to
address the recommendations
4 Adequate evidence is available to support the
level of progress
5
The actions implemented
have effectively addressed the recommendations identified in the IRS report
* The above ratings are not necessarily given equal weighting when generating the audit
opinion.
Design of Systems/Controls
The findings from our review have highlighted no issues that are classified
as a weakness in the system control/design for the IRS review follow-up.
Operation of System/Controls
The findings from our review have highlighted 3 issues that are classified as a weakness in the operation of the designed system/control for the IRS
review follow-up.
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6. Summary of Audit Findings
In this section we highlight areas of good practice that we identified
during our review. We also summarise the findings made during our audit
fieldwork.
Objective 1: An appropriate action plan was developed to address
the recommendations from the IRS review
We identified the following areas of good practice:
a sufficient action plan has been developed to focus on the recommendations from the IRS Review; and
the Health Board’s plan contains details of the actions identified to address all 8 recommendations and the 3 commentaries that were
made within the report. Actions within the plan have identified lead officers and implementation target dates.
We did not identify any findings under this objective.
Objective 2: The action plan was subject to appropriate
communication and approval
We identified the following areas of good practice:
the action plan was formally approved by the Mental Health Clinical
Governance Committee; and
the action plan was included in the July – September 2015 quarterly
Mental Health Directorate exception report that was presented to the Health Board’s Clinical Governance Committee.
We did not identify any findings under this objective.
Objective 3: Appropriate progress has been made with the
implementation of the agreed actions identified to address the recommendations
We identified the following good practice:
the Health Board’s November 2016 action plan identified that 7 of the
8 recommendations had been completed. Our discussions with management have confirmed that the recorded status is accurate and
the agreed 7 management actions have been appropriately implemented.
We identified the following finding under this objective:
the agreed action identified to address recommendation 10.6 (relating to re-visiting the Assessment Unit operational policy) from the original
IRS report has not been fully completed.
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Objective 4: Adequate evidence is available to support the level of progress
We identified the following finding under this objective:
we were unable to obtain documented evidence to fully verify and support the stated level of progress for 3 out of 8 recommendations.
Objective 5: The actions implemented have effectively addressed the recommendations identified in the IRS report
We identified the following finding under this objective:
we are unable to confirm that the action implemented in relation to
recommendation 10.8 (relating to consideration of the Medical staffing of the treatment Units) from the original IRS report has fully addressed
the finding. There is currently no evidence to confirm the outcome of the implemented action.
7. Summary of Recommendations
Our audit findings and recommendations are detailed in Appendix A
together with the management action plan and implementation timetable.
A summary of these recommendations by priority is outlined below:
Priority H M L Total
Number of recommendations
0 3 0 0
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Finding 1 – Documented evidence to support actions (Operational) Risk
The Health Board developed an action plan to address the recommendations raised in the IRS report. The action plan was approved by the Mental Health
Clinical Governance committee, and progress against the actions has been monitored by the Head of Nursing and the Assistant Director of Operations.
Our review of the Health Board’s action plan and our discussions with management has identified that 7 of the 8 agreed actions have been
completed. However, the action relating to recommendation 10.6 has not been fully completed and there was limited documented evidence to support the
Health Board’s assessment of ‘completed’ for 3 out of the 8 actions.
Our findings for the 4 actions where there was limited documented evidence
are set out below:
Recommendation 10.2
The numbers of medical staff in the Assessment Unit (AU) should not fall below three at any time.
Agreed action
Introduce a system of escalation if the number of medical staff in the AU falls below 3 in working office hours.
Internal Audit follow up
The system of escalation is for management to consider either using locum
cover or moving other staff into the AU to address any shortfall.
While the Head of Nursing confirmed that staff members have been verbally
The risks identified in the IRS review that resulted in the agreed
recommendations are not effectively addressed.
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advised of the system there is currently no documented procedure or flowchart
supporting this new process.
Recommendation 10.4
The quality and timeliness of the information received by the Assessment Unit
when patients are admitted should be regularly reviewed by the Ward Manager and the Assessment Unit consultant. Deficiencies in either quality or timeliness
of this information should be reported as an untoward event.
Agreed action
Ward Manager to include the recommendation to the 'trigger list' with trends reported to the Health Board’s Clinical Governance meeting.
Internal Audit follow up
The ‘trigger list’ identified within the agreed action has not been developed.
However, we note that incident trends are reported to the Mental Health Clinical Governance Committee, and we understand that staff members have
been told to ‘incident report’ any issues around information not getting to the Assessment unit. However, there is no documented evidence to confirm that
this has been discussed with staff members.
Recommendation 10.6
The numbers of admissions from CAMHS, learning disability services and older
adults’ services should be regularly monitored. Clear written care pathways for the management of sub-specialty patients admitted to the Assessment Unit
should be developed.
Agreed action
To revisit the Assessment Unit Operational policy to include more narrative and
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clarity regarding the pathways for CAMHS, learning disability and Older Adults.
Internal Audit follow up
We were unable to find any reference to learning disability in the Assessment
Unit’s updated Operational policy.
Recommendation 10.8
The Board may wish to consider the medical staffing of the treatment units:
provision of a more consistent or permanent presence of medical staff on those units (at consultant and specialty doctor level) may improve the throughput of
those wards. These doctors would also be available on site to cope with surges in demand from the AU, which, as has been previously noted, occurs at
unpredictable intervals.
Agreed action
The Clinical Director would discuss and advice if necessary.
Internal Audit follow up
The Head of Nursing confirmed that the recommendation was considered by the Assistant Director of Operations (ADO) and discussed with the Clinical Director.
However, there is no documented evidence to show that this occurred or the outcome of the discussion.
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Recommendation 1 Priority level
Management should ensure that appropriate procedures and / or other
documented evidence are in place to fully support the level of progress against these recommendations.
Management must also ensure that action 10.6 is completed as soon as possible and consider formally reporting completion of the action plan back to
the Mental Health Clinical Governance Committee.
Medium
Management Response 1 Responsible Officer/ Deadline
The issues of escalating concerns regarding medical staffing levels; recognising the trigger to incident report untimely or poor quality documentation and
reference to Learning difficulties will be added to the Admission Ward
Operational Policy and ratified through Clinical Governance.
The Directorate management Team will agenda a discussion regarding Consultant cover on the Treatment Wards and if felt that this is the direction of
travel will make recommendation to the Board.
Assistant Dir of Operations / Clinical Director / Head of MH Nursing
31st March 2017
Assistant Dir of Operations / Clinical
Director / Head of MH Nursing
28th February 2017
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Finding 2 – Discrepancy in reported figures (Operational) Risk
Evidence to support the agreed actions relating to IRS recommendations 10.1 (audit of admissions), 10.3 (review of non-face to face assessments), and 10.5
(data definitions when reporting to Welsh Government) is recorded within the Crisis Resolution Home Treatment (CRHT) data template that is submitted to
Welsh Government. The figures recorded should be the same as those within the Health Board’s dashboard that is reported to the Clinical Board Meeting
(CBM).
We compared a sample of 5 figures relating to referrals for crisis assessment
from the North and South from the data submitted to Welsh Government in April, June and September 2016 to the corresponding CBM dashboards to
establish if the information was consistent.
While the majority of the sampled figures were consistent, we identified a
difference between the June figures for the South relating to:
face-to-face admissions which were out by 1 (12/13); and
telephone admissions and follow-up assessments which were out by 10
(18/8).
We were unable to confirm why the differences had occurred.
However, our testing has confirmed that the requirement of the Health Board to complete the follow-up assessments for all telephone admissions within 24
hours was complied with in all cases.
The risks identified in the IRS review that resulted in the agreed
recommendations are not effectively addressed.
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Recommendation 2 Priority level
Management should ensure that there is a system in place to cross check the
figures before submitting to Welsh Government and the Clinical Board Meeting.
Management should review the June figures and make the necessary
adjustments to the crisis assessment data if appropriate.
Medium
Management Response 2 Responsible Officer/ Deadline
June figures will be reviewed and appropriate steps taken to remedy difference.
To explore possibility of using QLIK sense to manage the data in order to
reduce opportunity for human error when moving data from one template to
another.
Head of MH Nursing
28.02.17
Head of MH Nursing
31.03.17
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Finding 3 – Actions not addressing the recommendations (Operational) Risk
Recommendation 10.8 from the original report stated that ‘The Board may wish
to consider the medical staffing of the treatment units: provision of a more
consistent or permanent presence of medical staff on those units (at consultant and specialty doctor level) may improve the throughput of those wards.’
The November 2016 action plan records the required action as ‘Clinical Director to discuss and advice if necessary’. This action is recorded as ‘complete’ and, as
highlighted in finding 1 above, the Head of Nursing has confirmed that discussions took place.
However, while we acknowledge that the recommendation is of a ‘light touch’, it appears that the completed action does not address the ‘spirit’ of the
recommendation and may not therefore fully address the original report finding.
In addition, we were unable to confirm the outcome of the discussion to understand if any further actions were identified.
The risks identified in the IRS review
that resulted in the agreed
recommendations are not effectively addressed.
Recommendation 3 Priority level
Management must review the appropriateness of the agreed action to ensure that the original finding from the RCP report has been addressed.
Medium
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Management Response 3 Responsible Officer/ Deadline
The Directorate management Team will agenda a discussion regarding
Consultant cover on the Treatment Wards and if felt that this is the direction of
travel will make recommendation to the Board.
Assistant Dir of Operations / Clinical
Director / Head of MH Nursing
28th February 2017
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Action Plan
NHS Wales Audit & Assurance Services Appendix B
Audit Assurance Ratings
Substantial assurance - The Board can take substantial assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Few matters require
attention and are compliance or advisory in nature with low impact on residual risk
exposure.
Reasonable assurance - The Board can take reasonable assurance that
arrangements to secure governance, risk management and internal control, within those
areas under review, are suitably designed and applied effectively. Some matters require
management attention in control design or compliance with low to moderate impact on
residual risk exposure until resolved.
Limited assurance - The Board can take limited assurance that arrangements
to secure governance, risk management and internal control, within those areas under
review, are suitably designed and applied effectively. More significant matters require
management attention with moderate impact on residual risk exposure until resolved.
No Assurance - The Board has no assurance that arrangements to secure
governance, risk management and internal control, within those areas under review, are
suitably designed and applied effectively. Action is required to address the whole control
framework in this area with high impact on residual risk exposure until resolved
Prioritisation of Recommendations
In order to assist management in using our reports, we categorise our recommendations
according to their level of priority as follows.
* Unless a more appropriate timescale is identified/agreed at the assignment.
Priority
Level
Explanation
Management
action
High
Poor key control design OR widespread non-compliance
with key controls.
PLUS
Significant risk to achievement of a system objective OR
evidence present of material loss, error or misstatement.
Immediate*
Medium
Minor weakness in control design OR limited non-
compliance with established controls.
PLUS
Some risk to achievement of a system objective.
Within One
Month*
Low
Potential to enhance system design to improve efficiency or
effectiveness of controls.
These are generally issues of good practice for
management consideration.
Within
Three
Months*
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Agenda Item 5.1
Forward Look Mental Health Act Monitoring Committee
Page 1 of 2
Mental Health Act Monitoring Committee Meeting 15 June 2017
Mental Health Act Monitoring Committee: Forward Look 2017/18
15 June 2017 at 2.00pm Ynysmeurig House Abercynon
Standard Items:
Mental Health Act Breaches / Analysis of unlawful detention Director of PC&MH
Mental Health Act Monitoring Report – Quarterly Activity Statistical Report Director of PC&MH
Mental Health Crisis Care Concordat to include: update paper on progress to date South Wales Police
Risks related to Mental Health Act Monitoring Assistant Dir.Ops
Annual Report on Suicides Assistant Dir.Ops
Additional Items:
Invite Ian Wile to present the National Benchmarking data on Breaches Director of PC&MH
Receive the Internal Audit on the Mental Health Act S117 for review and monitoring from Audit
Committee 3 April 2017 Internal Audit Report - Royal College of Psychiatrists Review Follow up
Board Secretary
Receive an update from SWP on HMIC inspection report South Wales Police
Update on Suicide (Annual Report) Director of PC&MH
Committee Annual Report Board Secretary
14 September 2017 at 2.00pm Ynysmeurig House Abercynon
Standard Items:
Mental Health Act Breaches / Analysis of unlawful detention Director of PC&MH
Mental Health Act Monitoring Report – Quarterly Activity Statistical Report Director of PC&MH
Mental Health Crisis Care Concordat to include: update paper on progress to date South Wales Police
Risks related to Mental Health Act Monitoring Assistant Dir.Ops
Additional Items:
Annual Report Board Secretary
5.1 To review
the Forw
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Forward Look Mental Health Act Monitoring Committee
Page 2 of 2
Mental Health Act Monitoring Committee Meeting 15 June 2017
7 December 2017 at 2.00pm Ynysmeurig House Abercynon
Standard Items:
Mental Health Act Breaches / Analysis of unlawful detention Director of PC&MH
Mental Health Act Monitoring Report – Quarterly Activity Statistical Report Director of PC&MH
Mental Health Crisis Care Concordat to include: update paper on progress to date South Wales Police
Risks related to Mental Health Act Monitoring Assistant Dir.Ops
Additional Items:
Terms of Reference Director of Governance /Board
Secretary
NB - Urgent items will be accommodated as required and the Forward Look is subject to change.
Quarterly items Annual review of the Terms of Reference in line with the Standing Orders to take place in December 2017
Items to consider
Receive national benchmarking data on MHA Breaches when available Receive update paper from South Wales Police on the new Police and Crime Act requirements when available
5.1 To review
the Forw
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