Independent investigation: Fred Hodson, Luton (2011)

When organisational structures and policies are changed, there should be a mechanism to ensure that policy and practice changes are aligned, and any relevant forms or documents are updated accordingly.

Following a CRHTT assessment, the lead clinician should be responsible for checking with service users and carers that the outcome of the assessment is clearly understood, and next steps mutually agreed, with a documented note to that effect.

Following a CRHTT referral, the referrer should receive feedback on the outcome of the assessment on the same day, and be informed if there are any changes to the original assessment time or date.

The Trust should ensure there is practice guidance that provides a framework to support risk assessment and decision making about appropriate practical arrangements after an admission to Jade Ward has been agreed.

The Trust should ensure that communication with families is carried out in line with the Trust’s adverse incident policy, and follows guidance in the Memorandum of Understanding and best practice guidance and there are assurance systems that evidence this concordance … Read more The Trust should ensure that communication with families is carried out in line with the Trust’s adverse incident policy, and follows guidance in the Memorandum of Understanding and best practice guidance and there are assurance systems that evidence this concordance with policy. Show less

We suggest that NHS England develop an information resource for families who may become involved in an independent investigation.

The Trust should provide guidance regarding feedback mechanisms to staff involved following serious incident investigations.

The Trust should develop systems that provide assurance regarding the implementation of key policies such as adverse incidents.

The Trust should review the systems in place to sign off action plans from serious incidents, and ensure that there is an assurance process to evidence implementation and embedded practice changes.