Independent investigation: Geeta RaoLeela Rao, Wigan (2008)

North West

Incident 19 Feb 2008

Subject Geeta RaoLeela Rao

Paranoid schizophrenic repeatedly and fatally stab sister and mother

Report PDF Hundred Families

Acceptance Status

No Response Published 2

Total Recommendations 2

About this data

Acceptance Status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

Recommendations (2)

1 The Director of Nursing and Governance, the service managers and the clinical leads and team managers for all assertive outreach teams.

No Response Published

Recommendation

The assertive outreach teams at the Trust should review their current approach to the traffic light system used to zone clients on the caseload. The model used when Mr SR was a patient did not set out a robust and … Read more The assertive outreach teams at the Trust should review their current approach to the traffic light system used to zone clients on the caseload. The model used when Mr SR was a patient did not set out a robust and clear management framework for each zone. For example, for service users in the Red zone, it did not set out the maximum gap between medical assessments or the frequency of care co-ordinator assessments. Neither did the tool set out the rules by which a service user could be moved from the RED zone to the Amber zone, and so on. Because, in Mr SR‟s assertive outreach team, the traffic light system was used as a clinical management rather than workload management tool, it is essential that the tool is designed in such a way that its efficacy and reliability of use can be subjected to periodic audit. It is therefore recommended that the assertive outreach service managers, team leaders and clinical leads explore: the range of approaches currently in use across all Trust assertive outreach teams; approaches in other mental health trusts and other teams such as early intervention services; the range of criteria that might constitute a robust framework for dictating the necessity for clinical discussion of a service user at the weekly clinical team meeting, and/or the service user‟s escalation up the zoning system; the process by which service users, once escalated up the zoning system, can be „de-escalated‟. In conjunction with the above, it is recommended that: clear guidelines are developed for the zoning system agreed; documentation standards around clinical decision-making are agreed; the way the zoning system is to be audited, including audit criteria and the frequency of audit, is agreed and planned for. In formulating an appropriate audit process, the Independent Team recommends that at least the following factors are incorporated: The appropriateness of the traffic light level/zone; The quality of documentation when a decision is made to manage a service user outside of the protocol guidelines; The quality of documentation when a decision is made to move a service user to a lower risk tier of the traffic light system; Whether the documented frequency of medical review shows protocol compliance, and, where the frequency does not meet this, do the notes provide a reasonable explanation as to why? (E.g. a decision has been made for less frequent reviews and is a documented component of the management plan, or the service user has not attended for appointments); Appropriateness and frequency of medication review; Appropriateness of actions planned, following consecutive periods of non-attendance for planned contacts, that the traffic light system says requires action. Show less

2 The Director of Nursing and Governance, the service managers and the clinical leads and team managers for all assertive outreach teams.

No Response Published

Recommendation

This investigation identified a lack of knowledge about Mr SR‟s past history in the professionals directly engaged in his care and treatment. There was at the time an over-reliance on the information stored on the electronic record-keeping system. Had a … Read more