Independent investigation: Alan ScottStella Scott, Allerton, Liverpool (2008)

North West

Incident 31 Mar 2008

Subject Alan ScottStella Scott

Schizophrenic repeatedly and fatally stabbed parents. Previous inpatient

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 Medical Director; Nursing Director; Clinical Directors for each adult service CBU; Business Managers for each adult service CBU; the manager of the Patient Advice and Liaison Service; Mersey Care NHS Trust‟s Training and Education Manager.

No Response Published

Recommendation

Professional staff interviewed by the Independent Team identified a gap in their knowledge and understanding of alcohol and drug misuse. Interviewees also highlighted a gap in their knowledge base about the available resource in Liverpool to enhance this. The Independent … Read more

2 The Clinical Director and Business Manager for Liverpool CBU. Note: This recommendation could and should apply to all Clinical Business Units in Mersey Care NHS Trust.

No Response Published

Recommendation

All clinical business units in Mersey Care NHS Trust need to implement a more dynamic approach to how it audits and reviews the quality of clinical documentation. The quality of documentation was not of the standard expected in Mr SU‟s … Read more All clinical business units in Mersey Care NHS Trust need to implement a more dynamic approach to how it audits and reviews the quality of clinical documentation. The quality of documentation was not of the standard expected in Mr SU‟s community mental health records. In particular, there was no depth of information about how his mental state was being assessed, little about communications with other involved agencies such as supported housing, and a complete lack of up-to-date care plans. Although Mersey Care NHS Trust conducts audits of CPA and risk assessment documents via standardised audits, information gathered during the investigation process suggests that it does not sufficiently or consistently interrogate the quality of what has been recorded. Consequently, the Independent Team recommends that a peer review process is implemented where: A randomised selection of CPA and Risk Assessment documents and  progress notes are selected from the professionals participating in the peer review process; The group of peers reviews the documents selected and provides  constructive feedback on their completeness and also usefulness. The Independent Team suggests that a peer review of clinical records could be facilitated on a three- to four-monthly basis. The Independent Team also recommends that each professional‟s supervisor reviews the record-keeping for each of its supervisees across the professional‟s entire caseload on a rolling basis. Because documentation review is time-consuming, the Independent Team anticipates approximately two to three sets of records being reviewed at each monthly supervision session. To make delivery of this recommendation achievable, the following principles will be required: An agreement of what aspects of the clinical record should be  subjected to scrutiny; An agreement as to what proportion of each record needs to be  scrutinised. For example, would it be acceptable to review a contemporary CPA care plan in one set of records, and a risk assessment and crisis intervention plan in a different service user‟s records? To achieve the principle of proactive records review does not mean that for each set of records reviewed in a supervision session, the same documents need to be reviewed for each service user. Show less

3 Mersey Care NHS Trust‟s Director with responsibility for Carer Support and the Patient Liaison and Advice Manager.

No Response Published

Recommendation

Where a long-term service user ceases to have regular contact with his or her Carers, their needs do not simply end. As part of its ongoing commitment to supporting Carers, Mersey Care NHS Trust needs to find a way of … Read more