Independent investigation: Claire Wilson (& unborn baby), Grimsby (2009)

NAViGO should encourage senior clinicians to contact specialists by telephone about the management of actual or suspected physical comorbidity [e.g. organic brain disease], especially where there are abnormal findings, and to document these discussions. [see paragraphs 5.87, 5.88, 8.147] Read more NAViGO should encourage senior clinicians to contact specialists by telephone about the management of actual or suspected physical comorbidity [e.g. organic brain disease], especially where there are abnormal findings, and to document these discussions. [see paragraphs 5.87, 5.88, 8.147] Show less

NAViGO should ensure there are robust links between the inpatient consultants, the home treatment team and the outpatient consultants that allow for consultation and effective handover. [see paragraph 9.29]

NAViGO should audit the accessibility, content and timeliness of the summary of significant information about a service user, including 136 assessments, available on MARACIS2, to ensure it is available in an emergency and includes appropriate information. [see paragraph 10.17, 10.19] Read more NAViGO should audit the accessibility, content and timeliness of the summary of significant information about a service user, including 136 assessments, available on MARACIS2, to ensure it is available in an emergency and includes appropriate information. [see paragraph 10.17, 10.19] Show less

NAViGO should audit the mechanism for telling consultant psychiatrists and GPs that one of their service users has had a section 136 assessment that did not result in admission, to ensure it is prompt and robust. [see paragraph 10.18, 10.19]

NAViGO should ensure documented clinical supervision of junior doctors takes place and that case based discussion and scrutiny by the consultant of medical records and written communications completed by junior doctors are key tools in workplace based assessment. [see paragraph … Read more NAViGO should ensure documented clinical supervision of junior doctors takes place and that case based discussion and scrutiny by the consultant of medical records and written communications completed by junior doctors are key tools in workplace based assessment. [see paragraph 11.16] Show less

NAViGO should liaise with the local police service to ensure the process for confirming any informal joint agreements on managing people known to both services is robust. These agreements should be flagged up by information systems when any significant event … Read more NAViGO should liaise with the local police service to ensure the process for confirming any informal joint agreements on managing people known to both services is robust. These agreements should be flagged up by information systems when any significant event occurs. This is for people not involved with the forensic service or with any other formal joint process. [see paragraph 11.20] Show less

NAViGO should ensure current policy on the investigation of serious incidents reflects good practice, such as the guidance from the National Patient Safety Agency, particularly for supporting and interviewing staff and including: debriefing; support and counselling; facilitated discussion within the … Read more NAViGO should ensure current policy on the investigation of serious incidents reflects good practice, such as the guidance from the National Patient Safety Agency, particularly for supporting and interviewing staff and including: debriefing; support and counselling; facilitated discussion within the MDT; written information about the purpose and process of the investigation; interview techniques; being accompanied at interview and confirmation of the record of the interview. The policy should include a robust system of dating and version control for serious incident investigation reports and executive summaries. [see paragraphs 13.47, 13.48, 13.58] Show less

NAViGO should ensure all information given to service users by each department about confidentiality and data protection complies with national and local policy and does not conflict with NAViGO‟s clinical and managerial responsibilities. [see paragraphs 13.17, 13.51] Read more NAViGO should ensure all information given to service users by each department about confidentiality and data protection complies with national and local policy and does not conflict with NAViGO‟s clinical and managerial responsibilities. [see paragraphs 13.17, 13.51] Show less

The CTP should obtain evidence that all actions resulting from the internal investigation have been completed.

NAViGO should encourage senior clinicians to reflect on diagnostic uncertainty and discuss complex cases with peers on an informal basis in addition to discussions within the clinical team. Discussions must be documented in clinical records and in minutes of team … Read more NAViGO should encourage senior clinicians to reflect on diagnostic uncertainty and discuss complex cases with peers on an informal basis in addition to discussions within the clinical team. Discussions must be documented in clinical records and in minutes of team meetings. [see paragraphs 5.93, 8.151] Show less

NAViGO should ensure consultant psychiatrists either make or countersign a single entry in the clinical records that clarifies the formulation and opinion of the team after pulling together the opinions of different disciplines. This entry should include the rationale for … Read more NAViGO should ensure consultant psychiatrists either make or countersign a single entry in the clinical records that clarifies the formulation and opinion of the team after pulling together the opinions of different disciplines. This entry should include the rationale for treatment decisions especially when such decisions are controversial or not supported by clinical evidence or are off license. NAViGO should audit this standard. [see paragraphs 5.71, 5.73, 5.81, 5.89] Show less

NAViGO should ensure current operational guidance emphasises the potential benefit of contacting close associates of the service user, even if he has no formally identified carer. [see paragraph 5.86]

NAViGO should ensure psychologists‟ case loads and job plans are appropriate and reviewed on a regular basis. [see paragraph 8.31, 8.106]

NAViGO should ensure there is a robust system of supervision for clinical staff which does not rely on the supervisee raising their own concerns about individual cases. Supervisors should identify some cases for discussion and ensure that all cases are … Read more NAViGO should ensure there is a robust system of supervision for clinical staff which does not rely on the supervisee raising their own concerns about individual cases. Supervisors should identify some cases for discussion and ensure that all cases are discussed within an agreed timescale. [see paragraphs 8.70, 8.104] Show less

The CTP should ensure drug and alcohol services are commissioned to provide an appropriate and accessible service for mental health service users, including inpatients, with a clear mechanism to resolve problems between the services. [see paragraphs 8.119, 8.126] Read more The CTP should ensure drug and alcohol services are commissioned to provide an appropriate and accessible service for mental health service users, including inpatients, with a clear mechanism to resolve problems between the services. [see paragraphs 8.119, 8.126] Show less

NAViGO should finalise a policy for accessing drug and alcohol services, to ensure there are clear criteria for accepting mental health service users, including inpatients, and to establish a clear route to discuss problems between the services. [see paragraphs 8.119, … Read more NAViGO should finalise a policy for accessing drug and alcohol services, to ensure there are clear criteria for accepting mental health service users, including inpatients, and to establish a clear route to discuss problems between the services. [see paragraphs 8.119, 8.126] Show less

NAViGO should ensure there are robust systems for adults of working age teams to seek an opinion from the older people‟s service and for recording the outcome. [see paragraph 8.148]