Independent investigation: Abida Bi, Bradford (2010)

North East and Yorkshire

Incident 20 Sep 2010

Subject Abida Bi

Paranoid schizophrenic beats wife to death with crowbar. Long MH history. Prev. threats to kill wife. (Ind Inq 2012 Dineen)

Report PDF Hundred Families

Acceptance Status

No Response Published 3

Total Recommendations 3

About this data

Acceptance Status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

Recommendations (3)

1 BDCT

No Response Published

Recommendation

BDCT commissioned its own review of the CMHT under which Mr S was managed. The report of this review was published in March 2012. The Independent Team recommends that BDCT provides its commissioners with a detailed breakdown of its considerations … Read more

2 BDCT, the provider of its electronic records system, The Deputy Chief Executive/Director of Nursing

No Response Published

Recommendation

Safeguarding children Because the assessment of risk to children is central to the contemporary assessment of risk, and because it is a complex issue, BDCT and the provider of its electronic records system should consider including a dedicated section in … Read more

3 The Trust

No Response Published

Recommendation

Although the Trust’s internal investigation report demonstrated a sincere commitment to the conduct of an effective investigation, there are a number of elements that the Trust needs to improve to ensure that future investigations:  Maintain objectivity;  Deliver good … Read more Although the Trust’s internal investigation report demonstrated a sincere commitment to the conduct of an effective investigation, there are a number of elements that the Trust needs to improve to ensure that future investigations:  Maintain objectivity;  Deliver good practice standards in investigative interviewing techniques;  Demonstrate a good working understanding of how ‘root-cause analysis’ applies to mental health incidents such as homicide. To achieve the above, the Independent Team recommends the following:  That future investigation teams are considerably smaller than that convened for the Mr S investigation. It should be possible to deliver an effective investigation with a three-person team (one lead investigator, one medical advisor and one nursing/social care advisor). If other subject-matter advisors are needed, these could be accessed on an as-required basis.  Staff identified as ‘investigative leads’ must know how to conduct a good investigative interview and appreciate the value of:  the ‘tell all’ instruction;  broad open questions;  closed questions for clarification purposes;  the funnelling technique;  avoiding leading and asking questions in such a way as to suggest the answer;  avoiding expressing opinions during the interview. Investigative leads must also:  appreciate that the investigation is an ‘enquiry’ into what happened and to ensure that the investigation team understands this from the perspective of the professionals involved; it is essential that there is sufficient depth of exploration, not simply a question and answer approach;  appreciate the need for a forensic analysis and exploration of key aspects of clinical practice. This appreciation is an essential competency for an investigative lead.  Staff identified as investigative leads acquire a more complete understanding of how the National Patient Safety Agency’s human factors framework can be applied during the information analysis part of the investigation and how, from this process, root causes can be agreed on. Show less