Jump to 29 Recommendations

Independent investigation: Bertha Martin, Cleadon (2008)

North East and Yorkshire
Incident 24 Jun 2008
Subject Bertha Martin

Mentally ill woman fatally batters mother. Previously sectioned & violent, released without aftercare. Ind Inq 2014 NHS North

Report PDF Hundred Families
Acceptance Status
No Response Published 29
Total Recommendations 29
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 (29)

1. Northumberland, Tyne and Wear NHS Foundation Trust
No Response Published
Recommendation
The investigation panel considers that the Care Programme Approach (CPA) policy of Northumberland, Tyne and Wear NHS Foundation Trust should contain a specific provision that during inpatient admissions, patients with no previous community input should be placed on enhanced care … Read more
10. Organisations responsible for mental health nursing care planning
No Response Published
Recommendation
The panel considers it would be appropriate for a review/audit to take place in relation to the quality of the mental health nursing care planning process. This should include:  the dating and signing of the care plan by both … Read more
11. Organisations responsible for nursing care planning documentation
No Response Published
Recommendation
There was a considerable amount of information held in the nursing communication sheets relating to identified care plans rather than in the care plans themselves. The panel considers that this detracted from the effectiveness of the nursing care planning process. … Read more
12. Organisations maintaining clinical records
No Response Published
Recommendation
The clarity and legibility of all clinical records are essential qualities to enable appropriate and effective treatment to be delivered. The investigation panel recommends that standards of record keeping are subject to regular review.
13. Organisations involved in patient management and risk assessment
No Response Published
Recommendation
The panel recommends that where a vulnerable adult is identified within the risk assessment process as being cared for by a patient (upon discharge in May 2008, patient E resided with victim E), a carer’s assessment must be offered as … Read more
14. social or health care services; GP’s
No Response Published
Recommendation
The panel recommends that whenever a social or health care service has any concerns in relation to a service user, insofar as the potential risks that that individual may pose to a vulnerable adult or child, this information should be … Read more
15. Hospitals; agencies involved in discharge arrangements
No Response Published
Recommendation
When meetings are held at hospital to consider the discharge arrangements for a patient, it is important that all the agencies who are likely to be involved in the discharge arrangements are invited to attend and do attend insofar as … Read more
16. discharging medical team; hospitals
No Response Published
Recommendation
When a patient is discharged from hospital following an inpatient admission, on the day of discharge there should be a preliminary discharge letter sent to the patient’s GP outlining the discharge medication and follow up arrangements. A full account should … Read more
17. health professionals
No Response Published
Recommendation
Where there are concerns in relation to a vulnerable adult living at the patient’s home, it would invariably be appropriate for there to have been some professional oversight of home leave in order to inform the decision making process prior … Read more
18. all agencies; GPs
No Response Published
Recommendation
The investigation panel recommends that mandatory training in relation to safeguarding vulnerable adults should be offered to practitioners across all agencies, including GPs, to foster a collaborative approach (involving collective responsibility) when issues arise which relate to safeguarding vulnerable adults. … Read more
19. All agencies
No Response Published
Recommendation
All agencies should be mindful of their individual responsibility to initiate safeguarding procedures in relation to vulnerable adults where appropriate. There should be no assumptions made that other agencies will necessarily have done so.
2. inpatient services; inpatient team
No Response Published
Recommendation
In light of the above recommendation, the investigation panel further recommends that inpatient services should identify a CPA coordinator within three working days of a patient’s admission. This should be written into the acute inpatient services operational policies. It should … Read more
20. MDT meetings
No Response Published
Recommendation
When a MDT identifies that a patient is implicated in concerns relating to a vulnerable adult this issue should become a standard item for review within the MDT meetings.
21. Professionals involved in safeguarding procedures
No Response Published
Recommendation
When a patient is considered to present a risk to a vulnerable adult, unless it is considered inappropriate to do so, consideration should always be given to involving that patient directly in any safeguarding procedures which relate to the vulnerable … Read more
22. Professionals discharging patients
No Response Published
Recommendation
Before discharging a patient to a home environment in which a vulnerable adult is believed to reside, consideration should be given to exploring issues of the mental capacity of the individuals involved and whether they are capable of self-determination in … Read more
23. individual practitioners; professionals involved in the multiagency process
No Response Published
Recommendation
The effective functioning of the safeguarding vulnerable adults procedure relies upon accurate recording of information shared at safeguarding meetings and effective distribution of minutes to all of the professionals involved in the multiagency process. To enable the protection procedures to … Read more
24. social services; other agencies
No Response Published
Recommendation
Where risks have been identified and safeguarding procedures have been initiated, cases should not be closed by social services or other agencies until there has been a satisfactory resolution of the concerns. In any event all decisions should be clearly … Read more
25. Safeguarding adults boards
No Response Published
Recommendation
Safeguarding adults boards are encouraged to utilise the Association of Directors of Adult Social Services (ADASS) guidance note, ‘Carers and Safeguarding Adults – Working Together to Improve Outcomes’ (2011) to review local practice and learn from the findings of this … Read more
26. Professionals maintaining patient’s clinical notes
No Response Published
Recommendation
When a patient, who has been subject to detention under Mental Health Act 1983, becomes an informal patient (either by being discharged from the detention or as a result of the expiry of the section) there should be a clear … Read more
27. Organisations maintaining patient’s records
No Response Published
Recommendation
All clinical notes, including psychology, should be integrated within the patient’s records and be readily accessible to all professionals involved in the individual’s care.
28. GPs surgeries
No Response Published
Recommendation
GPs surgeries should consider the viability of instituting a ‘usual doctor’ system whereby a patient is assigned to a particular GP within the practice to assist in the continuity of care and communication with external agencies.
29. GPs practices
No Response Published
Recommendation
The investigation panel was informed as to an eight day delay in the processing of important information sent by fax to GP 6 by patient E’s Counsellor 1 in January 2008. GPs practices should review internal communication systems to ensure … Read more
3. community mental health teams (CMHT)
No Response Published
Recommendation
The investigation panel recommends that community mental health teams respond urgently to requests from inpatient services for the allocation of a CPA coordinator and that within five working days from the time of referral the allocated CPA coordinator makes contact … Read more
4. community mental health teams
No Response Published
Recommendation
The criteria for acceptance into the Community Mental Health Teams and the allocation of a CPA coordinator, should operate on the basis of a patient’s needs and not be simply led by the diagnosis. An inclusion criteria runs the risk … Read more
5. community services
No Response Published
Recommendation
Specifically, a diagnosis that a patient is suffering from a personality disorder and/or alcohol related difficulties should not result in any exclusion of the patient from community services following their discharge from hospital.
6. Organisations using risk assessment tools
No Response Published
Recommendation
The Sainsbury risk assessment tool used at the material time was considered by the investigation panel to be weak in relation to the protection of vulnerable adults. There should be provision within the risk assessment process to prompt and record … Read more
7. Organisations adopting risk assessment tools
No Response Published
Recommendation
The investigation panel recommends that the risk assessment tool which is adopted is a dynamic tool with the capacity to record ongoing incidents of risk and warnings so as to enable a more cohesive and comprehensive risk management plan to … Read more
8. health professionals; Multi Disciplinary Team (MDT) meetings
No Response Published
Recommendation
The investigation panel has established that the expressions of concern, alerts and relevant risk incidents were not recorded consistently within the risk profile documentation. Instead, the panel found that although records were made of these warnings, they were distributed throughout … Read more
9. medical staff; MDT; Northumberland, Tyne and Wear NHS Foundation Trust
No Response Published
Recommendation
Written notes from the weekly consultant ward review did not show recorded evidence of discussion on risk assessment and risk management. The panel recommends that a minimum standard is set for medical staff that at every MDT meeting (or at … Read more