Date of Board meeting:23rdFebruary 2011

Title of report:PB / RL Action plan from the Independent inquiry into the care and treatment of PB / RL at BroadmoorHospital

Title of director presenting:Director of High Secure Services

Paper number:WL1994

For decision For discussion For information

Purpose of the report:

To provide an updated summary of the PB/RL Action Plan arising from the Level 1 Inquiry

Action required:

To note the PB/RL Action Plan.

Summary of key issues

  • Actions/tasks completed.
  • Audit Plan
  • Evidence

Relationship with the Assurance Framework (Risks, Controls, and Assurance):

The PB/RL Action Plan supports CO1 and CO3

Care Quality Commission Registration Regulations:

Regulation 9 - Care and welfare of people who use the services.
Regulation 10 – Assessing and monitoring the quality of service provision.
Regulation 11 – Safeguarding people who use the services from abuse.

Summary of Financial and Legal Implications:

None specific.

Equality & Diversity and Public & Patient Involvement Implications:

None Specific.

ENCLOSURE F

Paper WL1994

WEST LONDON MENTAL HEALTH NHS TRUST

PB / RL Action plan FROM THE Independent inquiry into the care and

treatment of PB / RL at Broadmoor Hospital

A REPORT FROM THEDIRECTOR OF HIGH SECURE SERVICES

The Board is asked to note the contents of this report and note the progress made.

  1. INTRODUCTION

1.1On 25th April2004 at 1800 hrs, patient PBassaulted a fellow patient RL in the dining room of Luton ward, BroadmoorHospital. RL sustained serious injuries and died in FrimleyParkHospital on the 5th June 2004.

1.2.The initial incident was verbally reported to the April Trust Board.

1.3.Terms of Reference were agreed and the Clinical Team for Mr PB and Mr RL undertook a critical incident review of the incident on 26 May 2004. This review was limited in its scope and it was recognised that a Serious Untoward Incident [SUI] review would be taking place. At the time of the review Mr RL had not died.

1.4.An initial action plan was formulated and presented to the Trust Board in November 2004 (WL646). This action plan drew together the recommendations and actions following the internal critical incident review and the subsequent review of actions (Dr. K. Murray & Ms. J. Williams).

1.5.An Independent Inquiry into the care and treatment of PB and RL in BroadmoorHospital and the circumstances of the fatal assault on RL was commissioned by NHS London (formerly the North East London Strategic Health Authority) in 2005 following PB’s trial in March 2005. The terms of reference for the inquiry were finalised in July 2005.

1.6.In addition to the independent inquiry an Internal Serious Incident Review was commissioned by the Chief Executive of WLMHT on 7 June 2005, which Professor Christopher Kennard (Non-Executive Director of WLMHT) agreed the Chair.

1.7.The previous update report to the Board on the PB/RL Action Plan was in October 2010 (paper WL(2)1942).

2CURRENT POSITION

2.1.The Independent Inquiry Report was finally published in September 2009.

2.1.1.The Independent Inquiry Report had 84 recommendations that are wide ranging and not confined to Broadmoor hospital alone.

2.1.2.A total of 223 tasks were identified for action against the 84 recommendations.

2.2.The status of the recommendations/actions on the current action plan (Version 17 updated 21.01.2011), Appendix 1 attached, shows that all 84 recommendations are now complete and ‘ragged’ as green. There is therefore no Exception Report to present to the Board.

2.3.The finalised version of the action plan has been sent to Karen Green, Performance Manager at NHS London, and she has agreed the status of all actions as green.

2.4.A formal request has been made by the Director of High Secure Services to the Broadmoor Clinical Audit Committee for an audit plan to be drawn up. This will ensure that all actions and tasks are complete and any changes in operational policies and procedures, etc., are in compliance with the recommendations of the report and are being regularly monitored. This will also provide assurance to the Board that the recommendations and actions are now embedded in practice and ‘business as usual’.

2.5.Several recommendations from the Inquiry Panel referred to issues of bullying & harassment and the Trust policy related only to staff;there was no patient-specific policy. Consequently, Professor Jane Ireland from the University of Central Lancashire was commissioned to undertake research into aggression and attitudes towards patient bullying across the hospital. Her team spent several months during 2010 carrying out the research project across all wards in the hospital. Professor Ireland’s report was completed in December 2010 and plans are in place for her to visit BroadmoorHospitalin March to undertake feedback sessions to management and staff on her findings.

2.6.To assist in the auditing of the actions, a separate document categorising all the report’s recommendation under 15 headings has been produced and submitted to NHS London. These headings are: Admission Process; Bullying & Harassment; Care Planning; Clinical; Communications; Engagement & Observations: External Monitoring; External Governance; Patient Death Policy; Risk Assessment; Risk Management; Security; Supervision; Support for NoK; Tilt High Risk; Training.

2.7.As part of the ongoing progress in addressing the actions, several files containing evidence of compliance have been compiled.

2.8.The finalised version of the action plan (V17) is embedded in this document as Appendix 1 and can also be accessed from The Exchange.

The Board is asked to note the contents of this report and the finalised Action Plan Appendix 1.

Leeanne McGee

Executive Director of High Secure Services

February 2011

APPENDIX 1

PB/RL Action Plan Version 17(Final)

(Note the action plan is 76 pages.)

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