Independent investigation: Brian Marsh, Swindon (2007)

That a treatment and care pathway for service users with a diagnosis of Obsessive Compulsive Disorder (OCD) is established by the Trust in accordance with NICE Guidelines (CG31).

Where other agencies are working with or have a significant history of working with a service user who is involved in a serious untoward incident investigation, the internal investigation team should ensure their respective views are sought to inform the … Read more Where other agencies are working with or have a significant history of working with a service user who is involved in a serious untoward incident investigation, the internal investigation team should ensure their respective views are sought to inform the investigation process and subsequent organisational learning. This might include local authority, criminal justice, private or voluntary sector organisations. Show less

To consider how the organisational learning from the Trust’s serious untoward incident internal investigation report can be most effectively disseminated Trust-wide to key stakeholders who may not as yet have had the opportunity to access this information. Read more To consider how the organisational learning from the Trust’s serious untoward incident internal investigation report can be most effectively disseminated Trust-wide to key stakeholders who may not as yet have had the opportunity to access this information. Show less

That the use of clinical formulations within CMHTs be included in the appropriate Strategic Business Unit’s clinical audit programmes.

That the Trust’s clinical supervision procedure with CMHTs be included within the appropriate Strategic Business Unit’s clinical audit programmes, building on the audit carried out in the Adult Strategic Business Unit in 2009.

That implementation of the policy and procedures regarding ‘Investigating Safeguarding Allegations’ be included in the appropriate Strategic Business Unit’s Clinical Audit Programmes.

That the issue of appropriate grades of staff having access to the required level of training in ‘Investigating Safeguarding Allegations’ be reviewed to ensure that access opportunities and uptake for this training are adequate.

That the Trust reviews the training needs of Mental Health Teams with regard to awareness of and responsibilities as health professionals when domestic violence is alleged, suspected or observed.

That CMHTs’ training needs regarding clinical risk management in accordance with evidence-based/best practice are evaluated. The provision of appropriate skills update training should be developed as required.

That the Trust ensures that health care professionals are not given responsibility for service users with Obsessive Compulsive Disorder unless and until they have received appropriate training in the condition, its care and treatment.

That the Trust consider the need to develop Trust procedural guidance on the following (if this has not been done since the completion of this report): Suicide and serious self-harm Clinical risk management and the CMHT’s responsibilities with regards to … Read more That the Trust consider the need to develop Trust procedural guidance on the following (if this has not been done since the completion of this report): Suicide and serious self-harm Clinical risk management and the CMHT’s responsibilities with regards to actual or suspected domestic violence Medication non-compliance Show less

That the provision of Mental Health Teams’ access to OCD specialist advice (in accordance with NICE CG31) is addressed by the Trust and commissioners.

That the issue of staff accountability be a reporting criterion clearly acknowledged within subsequent serious untoward incident investigations.

In accordance with the Trust’s current procedural guidance, Terms of Reference for a Serious Untoward Incident investigation should be provided to the investigation team and clearly stated within future reports.

The National Patient Safety Agency (NPSA) Incident Decision Tree should be considered by an internal investigation team when determining possible system or individual failures within the organisation.

To provide Mrs A with the opportunity to receive the Trust’s findings, recommendations and actions taken from the Mr B serious untoward incident internal investigation report.

That a treatment and care pathway for service users with a diagnosis of comorbid brain injury and mental disorder is developed by the Trust in accordance with NICE Guideline (CG56).

That the Trust’s resource requirements to provide neuropsychological assessment services (including consultant assessment and case load management) are determined and considered as part of the Trust’s business planning process.

That the issue of the Trust’s mental health services having partnership working agreements with the Neurological Rehabilitation services be reviewed with commissioners as a service delivery priority.

That the Trust makes agreements with other agencies about how risk information will be shared with each other to ensure that critical information is not lost in the risk assessment and management process. This might include local authority, criminal justice, … Read more That the Trust makes agreements with other agencies about how risk information will be shared with each other to ensure that critical information is not lost in the risk assessment and management process. This might include local authority, criminal justice, private or voluntary sector organisations. Show less

Where a serious untoward investigation identifies system failures, timely assurance should be sought by the Trust (e.g. via clinical audit) to ensure such failures are not apparent within other teams.

The Trust should consider the potential clinical and organisational risks following any serious untoward incident investigation. Where appropriate: these risks should be ‘weighted’ (assessing the risk relative to other risks) the adequacy of controls (e.g. staff training, support and supervision … Read more The Trust should consider the potential clinical and organisational risks following any serious untoward incident investigation. Where appropriate: these risks should be ‘weighted’ (assessing the risk relative to other risks) the adequacy of controls (e.g. staff training, support and supervision levels) should be assessed treatment plans should be developed to reduce the risks. Show less

The Trust should consider whether or not the risks identified in this serious untoward incident investigation are evident elsewhere in the organisation and assure themselves that there are no significant risks still outstanding which have not been addressed. Read more The Trust should consider whether or not the risks identified in this serious untoward incident investigation are evident elsewhere in the organisation and assure themselves that there are no significant risks still outstanding which have not been addressed. Show less