Independent investigation: Albert Wright, Hainault (2011)

The Trust should develop systems that provide assurance regarding the implementation of key policies such as the assessment and management of clinical risk.

When organisational structures and policies are changed, there should be a mechanism to ensure that policy and practice changes are aligned, and any relevant forms or documents are updated accordingly

The Trust should review the policy for ensuring that service users are kept informed about their care, including copying correspondence to the service user.

Where a decision is made to change a service user’s diagnosis, this should always be communicated in a face to face discussion with the individual, allowing time for explanation and any concerns and questions. We believe the Trust should ensure … Read more Where a decision is made to change a service user’s diagnosis, this should always be communicated in a face to face discussion with the individual, allowing time for explanation and any concerns and questions. We believe the Trust should ensure this is embedded into practice. Show less

The Trust should review the services that are available for assessment and treatment for service users with personality difficulties along with other mental health issues.

The Trust should be satisfied that there is clear practice guidance for the management of risk items on admission to Jade Ward, and that any guidance on restrictions is reasonable, proportionate and necessary.

The Trust should ensure that communication with families is carried out in line with the Trust’s adverse incident policy, and follows guidance in the Memorandum of Understanding and best practice guidance and there are assurance systems that evidence this concordance … Read more The Trust should ensure that communication with families is carried out in line with the Trust’s adverse incident policy, and follows guidance in the Memorandum of Understanding and best practice guidance and there are assurance systems that evidence this concordance with policy. Show less

The Trust should review the systems in place to sign off action plans from serious incidents, and ensure that there is an assurance process to evidence implementation and embedded practice changes.