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6.21. The author notes that there is no multi agency protocol that underpins expectations of this process and
there is limited understanding of the process in other agencies. The plans appeared to be task
orientated based on risk patterns. It appears that the desired outcomes were related to keeping Josh
out of hospital but did not include identifying and addressing the issues that were consistently bringing
him into hospital. There were no set review meetings so, in effect, it was a stand-alone plan that was
not revisited.

6.22. Hospital staff stated that they felt uncomfortable with the plan and although they referred to it on each
subsequent admission, they felt it was not addressing Josh’s needs. Staff did not challenge the plan or
ask for a review. The plan was not circulated widely enough and police and ambulance services that
were responding to crisis points in the community did not know of the plan’s existence. Likewise,
housing services did not know of the plan. The homeless service team had been identified to be invited
by the clinician but were not included when the invitations were sent and therefore were not sent a
copy of the plan.

6.23. Whilst a wider circulation of the plan may have helped, the author considers that the plan was too
narrowly focussed. Had there been a wider focus and discussion of all of the issues that Josh was
facing, it may have been indicated that there was a role for social work and even safeguarding
enquiries. Those issues were:

 Inability to maintain a housing tenancy
 Ongoing use of heroin and cocaine and regular use of needle exchanges
 Debt and budgeting issues (now thought to be linked to drug use)
 Ongoing connections in substance misuse circles
 Consistently feeling that his situation was hopeless, and his only way out was death
 The expressed wish to reconnect with family

6.24. It was discussed during the review that the nature of the frequent attender process was necessarily
narrow. There was agreement, however, that a joint shared protocol could be inclusive of more
agencies in the initial phases to ensure all information pertaining to the person is included. It was also
agreed that there could be several different exit points or outcomes from sharing of such information
such as a wider multi-disciplinary team meeting or a safeguarding referral.

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6.25. There has been work undertaken nationally to manage frequent attenders to emergency departments
but also an acknowledgement that frequent attenders, whilst putting a huge burden on resources, have
very different reasons for their attendance and therefore ‘one size does not fit all’ in these cases.
Identified as useful in the management of frequent attenders are:

 Emergency departments should have a method of identifying ‘Frequent Attenders’ to their
department.
 Patients who attend the emergency department frequently should be treated with the
same care and respect as other patients.

6 The Royal College of Emergency Medicine Best Practice Guideline: Frequent Attenders in the Emergency Department August 2017

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