NHS

THE STATE HOSPITALS BOARD FOR SCOTLAND SCOTLAND

Date :

SMT Lead :

Ref :

1. Introduction

May 2012

Doug Irwin, Security Director

12/01

A Significant Untoward Incident (SUI) was commissioned as a result of an incident

which was reported through Datix on | |. A Suspension of Detentionvisit by a patient to his mother's house had been cancelled. This was due to the

patient terminating the outing due to a delay, associated with not being able to take

his computer with him and not being able to decorate his mother's house.

The terms of reference for the review were:

To investigate clinical decision making, documentation, communication and the

circumstances leading to the cancellation or~| | leave of absence on |~~| with consideration of how his computer came to he with him in the vehicle and

how decisions were made regarding his request to do decorating during the visit to

his mother.

2. Review Panel

• Gordon Skilling, RMO

• Peter Clarke, CPA Manager

• Stephen Fleming, Security

3. Process for Preparing Report

Interviews were held with the following staff:

Written statements were the following staff:

The following documents were also reviewed:

• Datix Report

• Suspension of Detention Policy

• Clinical Team Meeting Reports

• Patient's CPA documents

• Application for Outing and Suspension and Detention document

Page 1 of 5

4. Initial Report

4.1 Description of Incident

On the | | was due to attend his mother's home. He

wished to take his desktop computer along with him. The computer is kept in the

patient store, as the patient is not allowed to access it. In the weeks leading up to

the outing when the SOD was discussed at the clinical team meeting there had

not been any mention of the computer being allowed out of the hospital.

During the nursing handover to the day duty on the morning of |information was received that 11 would be taking his computer with him on his

home visit. Staff nurses j^g^g/ggMgEM HH were asked to takecharge of getting the patient's belongings ready including the desktop computer.

They stated that they were not directly involved in this decision and were only

following instructions.

arrived a\ the hub to take ■ on his visit at 9.30am On arrival

questioned whether the computer was to go with the patient as this was not a

normal request and was not included in the SOD documentation H was alsounaware as to whether || was allowed to take the computer. In order toascertain as to whether the appropriate permissions had been given,

attempted to contact | Bby telephone and pager respectively. As there was no answer they placed the

computer into the vehicle boot and proceeded to the vehicle lock with a view to

checking the permissions with the Security department.

The reasoning for the decision to take the computer out of the ward was

associated with length of time of the journey; the level of clinical activity within the

ward that day and the inability to contact the duty security manager. By placing

the computer in the vehicle, escorting staff intended to ascertain whether the

computer was indeed on the SOD documentation when they arrived at the

vehicle lock. If it was not then it could have been removed and returned to the

ward. Conversely, if the computer had not been put in the vehicle at the time, the

escorting staff would have had to return to the ward to collect it if the permissions

had been given thereby, causing further delay.

When in the vehicle lock, the patient stated that he intended to assist his mother

by decorating her house during the visit. Likewise, this was not written in the SOD

documentation and quickly dismissed by | | The || who had now been informed of the computer asked for it to be taken out

of the vehicle and returned to the | | patients store as it would not bepermitted to leave the hospital At this point it was noticed that H's photo ID nolonger resembled his current appearance due to | |, his photograph was

required to be taken before he would be allowed to leave the hospital.

At 10:30am patient ■ terminated the outing due to the excessive delay and

neither being able to take his computer nor decorate the house.

4.2 Other Relevant Factors

wished to[met with the patient on | | and heard that

paint and decorate his mother's house during the S.O.D outing,

indicated that this would not be possible but that he would discuss it with the

clinical team. As the patient did not receive any further feedback, he took it to be

that permission had been given.

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Although the computer is stored in the Hub, the patient can not access it as it has

been withdrawn from his possession. The original decision to purchase the

equipment was approved by his then clinical team in advance of the current

procedures having been agreed, compensation had been received by H

^commented in the interview that patient 11 was taking the computer tostore it at his mothers, as he has no further use for it within the hospital.

The Suspension of Detention documentation was correctly filled out by the

clinical team. On two separate occasions it was identified that the patient would

not be allowed to take any valuables on the outing, These were on the

Application for Outing and Suspension of Detention and the Initial proposal for

Suspension of Detention - Request for Information forms.

4.3 Additional Observations

The | | had followed the necessary procedures associated with SOD

outings for | | They liaised with the Local Authority who

expressed concerns with regards to|| coming into the area. It had taken fourmonths for the social work department to arrange this outing for patient ■

The full process took nine months in total beginning with initial discussions within

the clinical team to the proposed outing date. The earliest discussions regarding

| with regards to his proposed Suspension of Detention occurred in

the proposed outing was scheduled forf

5. Conclusions

All necessary procedures and measures were taken beforehand by the ward,

social worker, clinical team and the appropriate action was taken at time.

However, on the day of the outing, the appropriate documentation was

unavailable to the ward and escort staff whilst it had not been possible for the

escort staff to communicate directly with the security department. A decision was

made by the nursing staff and ^■■■M to proceed to the front gate in order toascertain whether the necessary permissions had been given. This decision was

made in good faith and consistent with the patient focussed care principle of the

Clinical Model. If the necessary documentation had been in their possession at

the time, the computer would not have been removed from the hub and the

outing would have proceeded without any complications.

6. Recommendations

• Documentation should be made clearer - Valuables and possessions should

be clearly specified and detailed to ensure no belongings leave the hospital that

are not listed on the documentation.

• A copy of the approved SOD documentation should be made available to the

nursing and escort staff, for example by RIO, as well as security to ensure

absolute clarity on exactly what belongings will be allowed to leave the hospital.

• Due to the length of time this particular outing has taken from the initial

discussions until the day of the SOD, it is recommended that a review of the

entire SOD process should be undertaken. This would be in keeping with TSH

clinical model principles section 6.2 Patient-focussed care.

Page 3 of 5

A Patient Property policy should be developed, which identifies the amount of

belongings that a patient can store and the procedures to be followed to

dispose of property that is no longer used by the patient.

Page rt of 5

Appendix 1 - Timeline of events

SUI - Suspension of Detention

Initial

discussions

by the

clinical team

regarding

patient

S.O.D

Initial

proposal for

SOD-

request for

information

form

completed.

Application

for outing

and S.O.D

completed

by key

worker.

Second

clinical team

consideration

for patient

S.O.D form

completed.

S.O.D

discussed at

Clinical tern

meeting. No

mention of

computer or

decorating.

First meeting

by the clinical

team of

consideration

for patient

S.O.D form

completed.

Security

assessment

completed

and signed

off.

Sociaf work

assessment

on proposal

for S.O.D-

Stage 1

Response.

CPA

review

meeting

regarding

S.O.D

S.O.D

Approval

form

completed.

Cancelled S.O.D-

Patient collected

from ward by rehab

staff at 09:00am to

leave for outing. At

10:20am outing

cancelled by patient

due to issues that

had not been

approved by clinical

team paperwork

and a further delay

caused by patient

requiring new photo

regarding his

change of

appearance.

Page 5 of 5