Independent investigation: Derek Brotherton, Bradford (2004)

Communication with the RMO (paragraph 93). This builds on recommendation 10 of the internal review (see Section 9 of this report). To ensure that the RMO is informed of any significant changes in circumstances or a patient’s condition, an audit … Read more Communication with the RMO (paragraph 93). This builds on recommendation 10 of the internal review (see Section 9 of this report). To ensure that the RMO is informed of any significant changes in circumstances or a patient’s condition, an audit should be conducted on at least an annual basis of all patients admitted to hospital over a defined period to record the time of identification of a defined risk threshold and the time senior medical input was requested and delivered. (paragraph 91) Show less

Roles and responsibilities of members of the AOT, Crisis Resolution and Home Treatment Team and the EDT (paragraph 88). This builds on recommendations 11, 13, 14, 19 and 20 of the internal review (see Section 9). (a) There should be … Read more Roles and responsibilities of members of the AOT, Crisis Resolution and Home Treatment Team and the EDT (paragraph 88). This builds on recommendations 11, 13, 14, 19 and 20 of the internal review (see Section 9). (a) There should be a joint agreement signed by the chief officers of the Trust and Social Services to specify the roles and responsibilities of all members of the AOT, the CRHT and the EDT. (b) There should be an agreed, documented operational policy on how the three teams work to best meet the needs of patients and carers, including specific reference to how cases are prioritised and how contact is made with patients and carers (c) There should be training for all staff on their roles and responsibilities and the operational policy (d) The working of the teams should be subject to annual review and the outcome of this review should be reported to the chief officers of the Trust and Social Services. Show less

Record keeping (a) The Trust should formally adopt the standards for record keeping required by the relevant national standards for the disciplines working at the AOT (paragraph 80) (b) Monitoring standards of record keeping and compliance with nationally recommended standards … Read more Record keeping (a) The Trust should formally adopt the standards for record keeping required by the relevant national standards for the disciplines working at the AOT (paragraph 80) (b) Monitoring standards of record keeping and compliance with nationally recommended standards should form part of the clinical audit programme of the Trust (paragraph 81) Show less

Involvement of staff in internal reviews (paragraph 73) When undertaking an internal review, all staff involved should be identified, the extent of their involvement identified and they should be given the opportunity to comment on that involvement.

Involvement of service commissioners (paragraph 76) A representative of service commissioners should be invited to attend appropriate post incident reviews carried out by provider organisations.

Incident Management Policy and adoption of SMART criteria for recommendations (paragraphs 77 and 86) The Trust should redraft its Incident Management Policy to ensure clarity of goals and processes to be followed, including the adoption of SMART criteria for the … Read more Incident Management Policy and adoption of SMART criteria for recommendations (paragraphs 77 and 86) The Trust should redraft its Incident Management Policy to ensure clarity of goals and processes to be followed, including the adoption of SMART criteria for the recommendations of any future service inquiries and reviews. The amended policy should be approved by the Trust Board and an audit should be done on an annual basis to review how the policy is working in practice. Show less

Monitoring of action (paragraph 91) The Joint Co-ordinating Group should be considered as the group for monitoring the implementation of recommendations affecting complementary services provided by the Trust and Social Services.