Independent investigation: Carl James, Swindon (2007)

The person completing the initial service management review must sign and date the report and set out his/her full job title. (S)he must also list the names and job titles of those contributing to the review and of those interviewed.

The Trust should ensure that its Medicines Management Policy is understood by all staff involved in its application and strictly adhered to, with particular reference to the administration and delivery of medication to a patient in his/her own home or … Read more The Trust should ensure that its Medicines Management Policy is understood by all staff involved in its application and strictly adhered to, with particular reference to the administration and delivery of medication to a patient in his/her own home or other place of residence. (See section, Medication Record Keeping, in Chapter 4 for further commentary on this issue) Show less

All discussions and decisions concerning a patient, and other information of relevance to his/her care, must be recorded in accordance with Trust procedure and national guidance.

An RCA panel investigating an incident of this gravity should be supported by a person, who understands the issues and is able to take comprehensive and attributed verbatim notes for greater understanding when referred to much later in the overall … Read more An RCA panel investigating an incident of this gravity should be supported by a person, who understands the issues and is able to take comprehensive and attributed verbatim notes for greater understanding when referred to much later in the overall Investigation process. Show less