Agenda and minutes

Venue: Council Chamber, Lambeth Town Hall, Brixton Hill, SW2 1RW. View directions

Contact: Anne Rasmussen, Email: arasmussen@lambeth.gov.uk, 020 7926 0028 

Items
No. Item

1.

Declarations of Pecuniary Interests

    Minutes:

    There were none.

2.

Minutes of Previous Meeting pdf icon PDF 82 KB

    To agree the minutes of the meeting held on 11 July 2012 as a correct record of the proceedings.

     

    Minutes:

    RESOLVED: That the minutes of the previous meeting be approved and signed by the Chair as a correct record of the proceedings.

     

3.

St George's Healthcare NHS Trust - Inquest into the death of Kane Gorny pdf icon PDF 59 KB

    • View the background to item 3.

    (Report no. 129/12-13)

     

    Contact for details: Elaine Carter, Lead Scrutiny Officer, 020 7926 0027, ecarter@lambeth.gov.uk

    Additional documents:

    Minutes:

    (Report no. 129/12-13)

     

    The Chair opened the debate by noting that this case had been described as a gross and avoidable death of a young man and expressed his deepest concern at this case. He also cited the coroner inquest into the death of three year old Isla Taylor. The Chair emphasised the need to ensure that lessons were learnt and that systems were improved to avoid similar situations in the future. 

     

    In response to queries from Members, representatives from St. George’s Hospital highlighted the following:

    • The Isla Taylor case was very complicated, and involved a three year old child who had tragically died as a result of a serious failure. The inquest into the death of Isla Taylor was concluded in September 2012
    • Following the Kane Gomy incident, systems within the hospital had been reviewed rigorously, including communications system across teams and handover procedures between teams.
    • The Medical Director, at the time, who was a surgeon, was closely involved in the investigation.  The resulting action plan implementation was led by the Surgical Division.
    • The death of Kane Gomy was caused primarily by the lack of endocrine input when Kane was admitted for surgery. Although this had been identified as a need at p[re-assessment, communication broke down and the endocrine team was not aware that he had been admitted. Following this incident, the pre-operative assessment unit has been further developed to ensure that agreed patient pathways are followed and that any deviations from this are flagged up at an early stage and addressed.
    • Numerous discussions have been carried out at the hospital to identify the best ways in which systems could be improved to avoid similar incidents in the future. Whilst systems and procedures have been amended and improved, the trust also aims to develop a safety culture within the organisation and amongst the staff and has used staff interest following the inquest to promote this. All staff are being encouraged to challenge any unsafe act and to accept challenges themselves, escalating if necessary within the organization. This demonstrates that the organisation is trying to achieve a more open and transparent culture, encouraging two-way conversations and creating a safer and more open culture which learns from errors.
    • Whilst it was likely that reduced capacity and increased pressures overall at the hospital in the future would impact on staff, it was important to note that this incident had been caused by lack of communication, not capacity issues.

     

    RESOLVED:

     

    (1)    To note the report and the actions taken by the Trust to address the issues.

     

    (2)    To agree that the Committee receive quarterly updates on serious incidents from within the trust.

     

4.

2012/2013 Budget Reductions Monitoring and Reporting pdf icon PDF 71 KB

5.

South London & Maudsley NHS Foundation Trust - Inquest into the death of Sean Rigg pdf icon PDF 59 KB

    • View the background to item 5.

    (Report no. 135/12-13)

     

    Contact for details: Elaine Carter, Lead Scrutiny Officer, 020 7926 0027, ecarter@lambeth.gov.uk

    Additional documents:

    Minutes:

    (Report no. 135/12-13)

     

    Marcia Rigg, sister of Sean Rigg, addressed the Committee, stating that she had worked closely with the mental health carers of her brother over a number of years but had been disappointed by the way in which Sean had been managed in recent years. For example, SLaM had allowed Sean to travel frequently to far away destinations and had often not take his medication. On the day of Sean’s death, he had not taken his medication and this has inadvertently caused his death. She expressed her disappointment that SLaM had not informed her that Sean had not taken his medication and noted that better systems should be put in place to ensure that communications channels stayed open even when permanent staff were on annual leave, as had been the case at the time of Sean’s death. The inquest into the case had found that SLaM had contributed to Sean’s death and it was vital that proper procedures and systems were put in place to avoid similar cases in the future.

     

    Matilda MacAttram from Black Mental Health UK asked that it be put on record that the inquest into Sean Rigg’s death had recorded that he had died at Brixton Police Station rather than at Kings College Hospital. She also noted that concerns flagged up with SLaM following the Sean Rigg case were not being addressed through community engagement work with BMH UK as promised and remained outstanding.

     

     

    The Chair thanked Marcia Rigg for attending the meeting and for campaigning for years on behalf of Sean to ensure that lessons were learned from this tragic case. He asked how further progress could be made to avoid similar incidents in the future.

     

    In response to queries from Members, representatives from SLaM made the following comments:

     

    • Further learning was required around the interface between SLaM and the Police, with a view to improve both the relationship between the two agencies and communication in difficult situations like that involving Sean Rigg. 
    • A serious incident had occurred the previous week at the Bethlem involving two patients at SLaM taking other patients and staff hostage. The police had been called for support but the incident had been managed well by staff at SLaM and the police did not get involved in the incident. This demonstrated that improvements had already been made to the way in which the Police and SLaM were working together and the team which was called in to deal with such situations were adequately trained.
    • Since the death of Sean Rigg, a zoning placement had been implemented within SLaM and this meant that any individual which was placed in the red zone was perceived to be high risk and would be assessed daily by a psychologist. However, it was recognised that this should have been introduced much earlier as this would have assisted in a quicker and more effective assessment of Sean Rigg.

     

    The Chair thanked all for attending the meeting, noting that this  ...  view the full minutes text for item 5.

6.

The Annual Report of Lambeth Safeguarding Adult Partnership Board 2011-2012 pdf icon PDF 70 KB

    • View the background to item 6.

    (Report no. 130/12-13)

     

    Contact details: Jane Gregory, Safeguarding Adult Policy and Development Coordinator, 020 7927 7707, jgregory@Lambeth.gov.uk

    Additional documents:

    Minutes:

    (Report 130/12-13 – agenda item 5)

     

    In response to questions raised by Members, the Divisional Director for Adult Social Care clarified the following:

    • Those cases described as ‘not determined’ as detailed on page 49 of the report, were usually a result of cases not being able to be investigated and closed properly, either because of lack of sufficient evidence or something else. However, even cases which were not determined would still be treated properly and care plans would be amended for those individuals to ensure that abuse would not result in the future.
    • The serious case review referred to in the report was investigated and evidence was found that the person in question was financially abused however, this was a long time ago and systems were now much improved.
    • CRB checks were carried out for staff directly employed by the Council and contractors providing services on behalf of the Council were also obliged to carry out CRB checks on carers. Whilst contractors were not currently obliged to provide the CRB to the Council, work was underway to ensure that at least a redacted form of the CRB check carried out were sent to the Council for information and further action where appropriate. Records of individuals with criminal convictions would be maintained and re-examined in the case of abuse.

     

    Councilor Clare Whelan asked what the implications were for Lambeth NHS and social care bodies of the Savile case.   DD Social Care, Adults and Community Services, undertook to ensure this was discussed at the next Safeguarding Board.   

     

    Councillor Jane Pickard noted that some abuse of vulnerable adults were carried out by family members so the issues were not purely relating to social care staff.

     

    RESOLVED:

     

    (1)          To note the report on activity between September 2011 and September 2012.

    (2)          To support the LSAPB’s proposals to develop safeguarding adult work in Lambeth over the next year. 

    (3)          To agree receive a written note on the issues discussed at the meeting in relation to CRB checks and the requirements of this to both the Council and its contractors.

     

     

     

     

7.

South London & Maudsley NHS Foundation Trust - Cost Improvement Programme pdf icon PDF 58 KB

    • View the background to item 7.

    (Report no. 136/12-13)

     

    Contact for details: Elaine Carter, Lead Scrutiny Officer, 020 7926 0027, ecarter@lambeth.gov.uk

    Additional documents:

    Minutes:

    (Report 136/12-13 – agenda item 6)

     

    RESOLVED:

     

    (1)   To note the report.

     

     

8.

Lambeth Addictions Service, South London and Maudsley NHS Foundation Trust - Proposal for Injectable Diamorphine Clinic pdf icon PDF 58 KB

    • View the background to item 8.

    (Report no. 132/12-13)

     

    Contact for details: Elaine Carter, Lead Scrutiny Officer, 020 7926 0027, ecarter@lambeth.gov.uk

    Additional documents:

    Minutes:

    (Report 132/12-13 – agenda item 7)

     

    Representatives from SLaM clarified the following:

    • The proposals had been trialled in a number of different countries and the treatment was now proven to work effectively for patients.
    • Treatment would only be offered to patients who had been living in Lambeth for a minimum of six months, this would prevent addicts from entering the borough and seeking this treatment.
    • Strong evidence suggested that this treatment had societal benefits and it was therefore considered to be a really positive development.
    • Consultation had been carried out with residents but further consultation could be carried out if necessary.

     

    The Chair commended the Addictions Service, SLAM on this example of  engagement and consultation with stakeholders.

     

     

    RESOLVED:

     

    (1)   That the committee consider the paper submitted by the Addictions Service, South London and Maudsley NHS Foundation Trust and submit any comments on the proposal to run an injectable diamorphine clinic at Lorraine Hewitt House, Brighton Terrace, Brixton.

     

9.

Proposals for Intermediate Care and Amputee Rehabilitation (Lambeth Community Care Centre and Pulross Intermediate Care Centre) pdf icon PDF 61 KB

    • View the background to item 9.

    (Report no. 137/12-13)

     

    Contact for details: Elaine Carter, Lead Scrutiny Officer, 020 7926 0027, ecarter@lambeth.gov.uk

    Additional documents:

    Minutes:

    (Report no. 137/12-13 – agenda item 8)

     

    Representatives from the Friends of Lambeth Community Care Centre addressed the Committee, noting that the centre was not well known to many people but added tremendous value to those that it served. She also noted that the Friends group was well aware of the need for the NHS to provide improvements and that the Friends were not opposed to change as a principle, however, given the benefit that the centre provided to parts of the community it was important that the good work and practices continued in the future. She asked that the consultation period be extended to ensure that all views were taken into consideration.

     

    Moira McGrath, NHS Lambeth, confirmed that the public engagement period had been extended to the end of December 2012.

     

    Councillor Lorna Campbell, Cabinet Member for Equalities and Communities, expressed her support for the views and requests from the Friends.  Councillor McGlone, Ferndale ward member, highlighted his concerns that he had not been aware of the proposals and consultation before the HASSC meeting.

     

    RESOLVED:

     

    (1)   That the Health and Adult Services Scrutiny Sub Committee note the work to date and proposed next steps and provide any comments on the proposals.

     

    (2)   Recommend that the consultation period be extended beyond Christmas and for a timeline as negotiated between interested parties. 

     

     

     

     

10.

Lambeth Local Involvement Network (LINk) pdf icon PDF 58 KB

11.

South London Healthcare NHS Trust pdf icon PDF 66 KB

    • View the background to item 11.

    (Report no. 138/12-13)

     

    Contact for details: Elaine Carter, Lead Scrutiny Officer, 020 7926 0027, ecarter@lambeth.gov.uk

    Minutes:

    RESOLVED:

     

    (1)   That a meeting of the Health and Adult Services Scrutiny Sub Committee be held on 5th December. This meeting will be held with Southwark Council’s Health, Adult Social Care, Communities and Citizenship Scrutiny Sub Committee and take place at Southwark Council, Tooley Street SE1 2TZ.

     

12.

Workplan pdf icon PDF 184 KB

    • View the background to item 12.

    (Report no. 134/12-13)

     

    Contact for details: Elaine Carter, Lead Scrutiny Office, 020 7926 0027, ecarter@lambeth.gov.uk

    Minutes:

    RESOLVED:

     

    1) That the committee note the 2012/13 work programme as drafted and status of actions, agree any further topics for scrutiny and determine when such items be considered (Appendix 1).

     

    2) To note the proposal (report elsewhere on this agenda) for an additional meeting held jointly with Southwark Council’s Health, Adult Social Care, Communities and Citizenship Scrutiny Sub Committee on Wednesday 5th December at Southwark Council, 160 Tooley Street SE1 2TZ.

     

    3) That the committee note the service change proposals notified by NHS Lambeth and decide whether these matters be subject to further scrutiny:

     

    I. SLAM Eamon Fotrell Day Centre (Appendix 2)

    II. SLAM Continuing Care Beds (Appendix