Case study: NHS Norfolk

This case study was developed prior to the NHS Listening Exercise. The outcomes of this exercise have led to some changes to the policy, and this case study may not reflect the current policy position. More information can be found in our detailed response to the NHS Future Forum.

This case study explores nurse-led collaboration between the local mental health trust and the A&E department in Norfolk. The aim was to improve the care for vulnerable adults sectioned under the Mental Health Act, and to ultimately reduce the number of admissions to A&E.

Background
A multi-agency meeting was held to look at how risks relating to absconding patients were being managed by both agencies, and to identify how vulnerable adults could be safeguarded in similar incidents. The following key issues were highlighted:

  • The frequency of Mental Health patients’ attendance to A&E
  • Poor communication pathways between the agencies
  • Unclear expectation of nursing staff in their duty of care to protect mental health patients
  • Lack of protocols in relation to accompanying a patient under section and access to a patient’s care plan regarding the need for restraint
  • Only two staff chaperoning, therefore unable to restrain as technique requires three
  • A&E staff without skills to understand mental health conditions and management of the patient
  • Patients left in waiting area increasing the risk of opportunistic abscondin.

Actions
The relevant clinical groups met, facilitated by the lead nurse for safeguarding adults, and agreed the following actions:

  • Clinical protocols in place for nursing staff to ensure explicit understanding of how escort duties should be managed
  • That as restraint was part of the patient’s care plan, the level of escorts needed to reflect a safe number of staff
  • Better planning of the visit would allow the mental health staff to organise staffing to support this
  • A system of triage for mental health staff  was developed to determine if the incident needed to be managed as:
    • An emergency visit to A&E
    • A planned same day visit
    • Next day clinic appointment
    • Managed on ward by nursing / medical staff

This involved a triage criteria, wound management & assessment training and management of ingestion of foreign bodies support for the staff. There was also involvement from local Emergency Care Practitioner staff in order to provide external clinical support to ward staff if necessary

  • Nurse to nurse handover from ward to A&E department / clinic to agree timeframe for visit if clinical triage allowed – and to ensure a place of safety could be identified for a patient within the department. Ensuring clear details of the incident / injury was provided so that A&E staff could prepare for the visit
  • Nurse escorts would support a clinician from A&E in providing the intervention, reducing the need for additional input from department staff
  • The agreed processes would form the basis for all attendances by patients from the mental health trust
  • Additionally the acute trust has agreed to flag frequent attendees to A&E and monitor issues that may assist in resolving attendances

What changed?
There was overall improved management of the patients’ incidents, with more being dealt with on the ward. More effective usage of time and communications between the two organisations resulted in improved patient safety and clearer boundaries.

All actions agreed will be monitored and reviewed to ensure that they remain appropriate and current and provide an improved service to vulnerable adults.

The safeguarding framework that sits within provider contracts will be updated in order to better reflect the need for integration of clinical care pathways to support vulnerable adults.

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