Jump to 36 Recommendations

Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000)

London
Incident 20 Aug 2000
Subject Geraldine Sureda(Mrs S)

MH patient kills mother whilst on w/e leave from Springfield psych.hospital, Tooting. Ind Inq 2006 found catalogue of errors

Report PDF Hundred Families
Acceptance Status
No Response Published 36
Total Recommendations 36
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 (36)

1 Trust
No Response Published
Recommendation
The Trust should ensure that their mental health service is organised in such a way that the health and social care and Local Authority elements are fully integrated and jointly managed
10 Trust
No Response Published
Recommendation
Where a serious incident involving a patient takes place outside the hospital, the clinical staff should use their best endeavours to obtain precise and full details of the incident so that an appropriate risk assessment can be made
11 Trust
No Response Published
Recommendation
There should be a designated member of the mental health and social care team whose responsibility it is to develop and maintain contact with family or carers or anyone who can provide valuable information about the patient
12 Trust
No Response Published
Recommendation
Consideration should be given to whether there should be a Trust protocol to cover Recommendation 8 so that such designated liaison team member can reassure the ‘informant’ that this is Trust policy in every case and not personal to their case
13 Trust
No Response Published
Recommendation
There should be a separate section in each patient’s notes for third party information in order to protect the confidentiality of the informant
14 Trust
No Response Published
Recommendation
Each ward should have an agreed operational policy which should be developed through discussion with the multi-disciplinary team and the relevant directorate. The operational policy philosophy should then be translated into a set of operating standards which are compatible with … Read more
15 Trust
No Response Published
Recommendation
The Trust should assess the degree to which they have made available clinical leadership and ward management development opportunity in order to ascertain • how much already exists • whether it is adequate • what more they need to do
16 Trust
No Response Published
Recommendation
If such assessment as described in Recommendation (15)highlights any deficiencies in any of these areas, they should be addressed and redressed as soon as possible
17 Trust
No Response Published
Recommendation
A development programme which secures effective team-based clinical and managerial leadership should be implemented systematically throughout the Trust on an ongoing basis
18 Trust
No Response Published
Recommendation
The Trust should review the adequacy of the length of time and quality of ward handovers to ensure that sufficient time is made available for effective clinical communication and teaching
19 Trust
No Response Published
Recommendation
All Named Nurses should arrange one to one time with each patient for whom they are responsible at least once a week, and a record of any conversation should be recorded in the notes
2 Trust
No Response Published
Recommendation
Seacole Ward should be subjected to a review by the Chief Nurse as a matter of urgency and a report submitted to the Trust Board and the Strategic Health Authority by the end of July 2005 so that the Trust … Read more
20 Trust and Local Authority
No Response Published
Recommendation
All members of the multidisciplinary team should have access to clinical and casework supervision and consultation
21 Trust
No Response Published
Recommendation
Clinical supervision must be addressed, monitored and audited, possibly through the clinical governance mechanism
22 Trust
No Response Published
Recommendation
The guidelines as to the role of a Named Nurse should be clarified and should incorporate the previous Recommendation
23 Trust
No Response Published
Recommendation
When patients are allocated to the care of certain nurses, on each shift throughout the 24 hour period, the nurses should make specific time to engage with the patients in his/her charge. If there is a persistent problem from the … Read more
24 Trust
No Response Published
Recommendation
Where a patient is consistently not eating the food provided by the hospital, this should also be reported as a significant feature of the patient’s presentation and a therapeutic strategy should be devised to address this difficulty
25 Trust
No Response Published
Recommendation
No deliveries should be allowed to the wards after 22.00 hours
26 Trust
No Response Published
Recommendation
There should be an agreed policy, based on the principle of no blame, to address interpersonal conflicts which, if left unresolved, place patients and staff at risk
27 Trust
No Response Published
Recommendation
Any long term patient with complex needs should have a thorough assessment which identifies and addresses their rehabilitation needs, taking into consideration any previous participation in rehabilitative programmes and any current expressed preferences Read more
28 Trust
No Response Published
Recommendation
In accordance with such assessment, appropriate activities should be made available on and off the ward, and priority should be given and resources applied to providing sufficient activities to meet demands
29 Trust
No Response Published
Recommendation
The Rehabilitation Service should be reviewed and appropriately resourced to ensure that those in need of its services do not have to wait long periods of time to be assessed and assisted
3 Trust
No Response Published
Recommendation
The Risk Assessment form should be kept separately from the rest of the notes in a prominent section of the notes so that it is a dynamic and easily accessible document and preferably should be colour-coded so that it is immediately recognizable
30 Trust
No Response Published
Recommendation
Every matter which is considered significant enough to be reported in a ward round should be recorded in the notes
31 Trust
No Response Published
Recommendation
All telephone calls made to a member of the clinical staff from relatives or friends of a patient which are in any way relevant to a patient must be recorded in the notes and detail of the content given
32 Trust
No Response Published
Recommendation
Patients who present with dual diagnosis involving misuse of illicit substances and/or alcohol should be referred for specialist assessment to secure an appropriate clinical management plan, or at the very least be subjected to routine screening for such substances Read more
33 Trust
No Response Published
Recommendation
Moves between wards/hospitals should only take place within the context of the treatment plan, except in an emergency or when ward closure is the reason for the move
34 Trust
No Response Published
Recommendation
The Trust should draw up an Action Plan in the light of these Recommendations
35 PCT
No Response Published
Recommendation
The PCT responsible for commissioning Trust services should consider the resource implications of the Recommendations made in this Report and draw up an investment plan accordingly
36 Trust
No Response Published
Recommendation
The Inquiry Panel should be invited to meet with the Trust in 12 months time to see what progress has been made in addressing the problems highlighted in this Report and its Recommendations
4 NHSE
No Response Published
Recommendation
Consideration should be given to the development of a nationally standardized proforma Risk Assessment
5 Trust
No Response Published
Recommendation
Every Risk Assessment form should be signed off by the patient’s consultant
6 Trust
No Response Published
Recommendation
The patients’ Risk Assessment should be regularly reviewed and updated at least every 6 months
7 Trust and Local Authority
No Response Published
Recommendation
Where risk to others has been identified, especially risk of physical harm, a management plan must be drawn up to deal with such risk, in keeping with the requirements of adult and vulnerable adult protection
8 Trust
No Response Published
Recommendation
When a patient is handed over by the forensic mental health team to the general team, a Risk Assessment form signed off by the consultant should be prepared and handed over. We recommend that attached to the Risk Assessment form … Read more
9 Trust
No Response Published
Recommendation
Consideration should be given to the establishment of an appeal system in the event of a request for a referral from the general service to the forensic service being refused