Independent investigation: Carmelita Tulloch, Vauxhall, London (2006)

A number of the findings relate to core practice that would be expected and required of community staff, for example, managing and undertaking thorough risk assessments, completing clinical documentation and completing forensic risk histories. The Trust should develop core competencies … Read more A number of the findings relate to core practice that would be expected and required of community staff, for example, managing and undertaking thorough risk assessments, completing clinical documentation and completing forensic risk histories. The Trust should develop core competencies for community staff, including medical staff, which will include the requirements for staff to work to established policy and procedure and to specify what actions need to be undertaken. The core competencies should be completed with care coordinators as part of the appraisal process. Team managers should also work towards core competencies which ensure that they know what is expected of them as part of their management role. Show less

The potential of the Trust Integrated Record System should be maximised to ensure that it delivers a focussed breakdown by team and by care coordinator to be available on the: · completion of Care Programme Approach reviews; · completion of … Read more The potential of the Trust Integrated Record System should be maximised to ensure that it delivers a focussed breakdown by team and by care coordinator to be available on the: · completion of Care Programme Approach reviews; · completion of risk assessments; · completion of child in need risk screens; · frequency that carer assessments are offered. Show less

A policy review took place during 2008. The policy review included a review of the brief risk screen. The revised Policy on the Framework for Clinical Risk Assessment and the Management of Harm was ratified in September 2008. The Trust … Read more A policy review took place during 2008. The policy review included a review of the brief risk screen. The revised Policy on the Framework for Clinical Risk Assessment and the Management of Harm was ratified in September 2008. The Trust should conduct a full audit following the publication of the Independent Investigation Report to ensure that the revised policy is operating effectively and that any further revisions are made as necessary. Show less

The Trust’s Care Programme Approach Policy was reviewed during 2008 in light of new Department of Health Guidance. A revised Trust Care Programme Approach Policy was published in September 2008. The policy contains details of the Trust’s response to the … Read more The Trust’s Care Programme Approach Policy was reviewed during 2008 in light of new Department of Health Guidance. A revised Trust Care Programme Approach Policy was published in September 2008. The policy contains details of the Trust’s response to the needs of carers. The revised policy was publicised to staff through line management channels, and Directorate Clinical Governance Committees. The Trust should conduct a full audit following the publication of the Independent Investigation Report to ensure that the revised policy is operating effectively and that any further revisions are made as necessary. Show less

The Lambeth Carer Strategy is a new approach which was introduced into the Trust in 2008. This strategy was developed by local Voluntary Groups, the Local Authority and NHS agencies. The strategy is easy to understand and based on thorough … Read more The Lambeth Carer Strategy is a new approach which was introduced into the Trust in 2008. This strategy was developed by local Voluntary Groups, the Local Authority and NHS agencies. The strategy is easy to understand and based on thorough research and understanding of the Borough of Lambeth. This strategy has made a robust attempt to engage with ethnic minority groups within the Borough to ensure its relevance and success. The Trust should conduct an audit against the effectiveness of this strategy on the publication of this report and make any necessary revisions. The audit should as a basic minimum: · determine how many carer assessments have been offered; · determine how many carer assessments have been accepted; · determine the ratio of carer assessments taken up by BME carers; · determine the quality and effectiveness of the resulting care plans. Show less

Existing policies and procedures regarding the liaison with the YOT/probation should be reviewed in the light of the lessons learned from the Mr X case and revised accordingly.

A new system for referral has been developed by one of the CAMHS Consultant Psychiatrists which has been approved by the Trust and has been in place since 12 November 2008. The Trust reports that this new system is working … Read more A new system for referral has been developed by one of the CAMHS Consultant Psychiatrists which has been approved by the Trust and has been in place since 12 November 2008. The Trust reports that this new system is working effectively. At the time of writing this report the Trust planned to send out GP and Partner Agency Information Packs. It is unclear what audit processes have been deployed to assess how well this new process is working. It is recommended that this process is reviewed specifically in the light of communications with GPs and audited to this effect within six months of the publication of this report. Show less

The existing clinical supervision policy should be reviewed and an audit conducted to ascertain its effectiveness. Any necessary revisions should then be made.

All Team Leaders/Managers should have key responsibilities regarding clinical and caseload supervision in their job descriptions and should be appraised to ascertain their performance in this area.

Trust clinical supervision processes should be directly linked to extant Trust professional regulation processes to ensure that any notifications of poor practice are acted upon with immediate effect.

The Trust’s Human Resources department should have in place a system of identifying transferable qualifications of overseas trained psychologists and ensure that qualifications, skills and experience are commensurate with current United Kingdom requirements. Read more The Trust’s Human Resources department should have in place a system of identifying transferable qualifications of overseas trained psychologists and ensure that qualifications, skills and experience are commensurate with current United Kingdom requirements. Show less

The Trust should conduct an audit within the Lambeth-based CAMHS to assure the Trust Board that clinical records are being contemporaneously made.

The Trust Information Technology Team must ensure that clinical records cannot be amended by any member of a clinical team following a serious untoward incident.

That the Service Level Agreement ratified on the 10 June 2007 between the CAMHS and the Lambeth YOT is audited to ensure it is working properly and is fit for purpose.

That the system introduced in November 2008 for referral to the Lambeth CAMHS is fully audited to confirm that it is working well and is fit for purpose.

The Trust acknowledges the far reaching nature of the independent investigation and the opportunity that this provides for organisation-wide learning. The Trust should arrange learning feedback sessions to enable the findings of this investigation to be raised with a wide … Read more The Trust acknowledges the far reaching nature of the independent investigation and the opportunity that this provides for organisation-wide learning. The Trust should arrange learning feedback sessions to enable the findings of this investigation to be raised with a wide audience and to help ensure that lessons are learnt. Show less

The Trust should develop strategies to ensure that condolence; support and advice are offered to the families / loved ones of the victims of homicide without this endangering the police investigation and judicial processes, and that the Being Open Policy … Read more The Trust should develop strategies to ensure that condolence; support and advice are offered to the families / loved ones of the victims of homicide without this endangering the police investigation and judicial processes, and that the Being Open Policy (2008) is reviewed as necessary and fully implemented. Show less

Structured Investigations and Board Level Inquiry reports should be thoroughly examined to ensure that the recommendations are SMART. Examination should take place prior to the report’s submission to the Serious Untoward Incident (SUI) Panel, at the SUI Panel and at … Read more Structured Investigations and Board Level Inquiry reports should be thoroughly examined to ensure that the recommendations are SMART. Examination should take place prior to the report’s submission to the Serious Untoward Incident (SUI) Panel, at the SUI Panel and at any Board Level Inquiry. The Board Level Inquiry should have an examination of the recommendations as a routine part of the inquiry terms of reference. Show less

The findings of the independent investigations should be raised and discussed at: · forthcoming Child Safeguarding conferences; · in Trust newsletters and Patient Safety Bulletins; · Police Liaison Committees.

Where there are actions arising from investigations into inpatient suicides and homicides the action plans should automatically be made a standing agenda item at the relevant Borough-based Clinical Governance Committee(s). Clinical Governance Committees should, as part of their terms of … Read more Where there are actions arising from investigations into inpatient suicides and homicides the action plans should automatically be made a standing agenda item at the relevant Borough-based Clinical Governance Committee(s). Clinical Governance Committees should, as part of their terms of reference, include an examination and review of any newly ratified Trust policies and procedures. An audit process should be in place to ensure that the policies and procedures are subsequently audited with involvement from clinical staff that work at the point of patient care. Show less

The current nursing practice assessment visits should continue on an annual basis. The terms of reference for the visits should be reviewed and amended in the light of the findings of the independent investigations.

The terms of reference for structured investigations and Board Level Inquiries should include an examination and assessment of compliance with Trust Policy and Procedure which includes: · Care Programme Approach; · Risk assessment and management of harm framework; · Clinical … Read more The terms of reference for structured investigations and Board Level Inquiries should include an examination and assessment of compliance with Trust Policy and Procedure which includes: · Care Programme Approach; · Risk assessment and management of harm framework; · Clinical records standards. It was apparent during the course of this investigation that the Memorandum of Understanding Investigating Patient Safety Incidents Involving Unexpected Death or Serious Harm: a protocol for liaison and effective communication between the National Health Service, Association of Chief Police Officers and the Health and Safety Executive 2006, was not clearly understood by either the Trust or the Police Service. A high-level discussion needs to take place to avoid further confusion in the future and to ensure that victims’ families are communicated with in a timely and helpful manner. Show less

NHS London, the London Strategic Health Authority, should engage in discussions with the Metropolitan and City Police Forces to ensure that the Memorandum can be implemented effectively.