Page 15 - TSAB Adult B FINAL (1)

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 Patients may benefit from a bespoke emergency department care plan.
 Patients should be given the opportunity to be involved in the production of their care
plans and be given a copy of the plan wherever possible.
 Case management for Frequent Attenders may be helpful to identify unmet needs for
patients.
 Multidisciplinary case conferences are recommended to improve engagement with
community services for some patients. They are also helpful to manage risk for certain
patients with risky behaviour.

6.26. It does appear that the current process would benefit from being a multi-agency process that takes into
account the above. It would benefit from being person centred and outcome focussed; reducing
emergency department attendance may be only one outcome. The process may also lead to other
system and agency referrals and reach all agencies that a person has contact with.

Learning Point 4: Multi Agency Processes can be more effective when underpinned by a
shared protocol.
Learning Point 5: Management of frequent attenders should consider the reasons for
attendance as well as plans for preventing/limiting attendance.
Learning Point 6: Frequent attender meetings may have more successful outcomes if
they attract a broader number of agencies, are outcome focussed, have set review dates,
produce minutes and plans shared to all relevant agencies (not just attendees).

SUBSTANCE MISUSE & MENTAL CAPACITY

6.27. It has become apparent in gathering information for this review that Josh was using illicit drugs on top
of his prescribed methadone more than had been originally thought. The dangers and risks of overdose
had been explained to him by substance misuse workers in Area A and Area B. It is identified by
examining the dates, that Josh, on at least one occasion, used a needle exchange facility on 2 days at
the point of discharge and readmission (Day 35 and 36). Comments from partners indicated that he
never appeared under the influence of drugs, this could indicate a significant tolerance level to
substances.

6.28. Mental health and acute trust professionals had not recognised the level of substance misuse, although
mental health workers did know he was still using illicit substances. There appears to have been some
level of communication between Area A substance misuse services and mental health and acute
hospital colleagues. This, however, did not lead to the knowledge by acute hospital staff, GP,
ambulance or housing of the use of the needle exchange and disclosures of heroin and cocaine use at
around the first and second hospital admissions.

6.29. One of the reasons that this information was not known was possibly because substance misuse
services in Area B had not been able to assess Josh when he transferred as he had not attended
appointments. There had been a full and comprehensive risk assessment in place in Area A, but this was
not transferred to Area B on closure of the substance misuse services in Area A.

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