Independent investigation: Halimah Ahmed, Derby (2007)
MidlandsPsychiatric patient smothers girl then hangs himself. Ind Inq 2010. & Coroners report. Prev violence – Known risk – tried to section 3 times but no S/W
Recommendations (9)
Eight
Derbyshire Mental Health Services NHS Trust
No Response Published
Recommendation
That the Trust issues a clear policy statement with regard to the transportation of service users in health and social care worker’s cars. This policy statement needs to cover:
• risk assessment;
• insurance;
• lone worker safety.
Five
Derbyshire Mental Health Services NHS Trust
No Response Published
Recommendation
The Trust should liaise with local community-based BME groups and networks in order to understand better the cultural sensitivities of the population that it serves. Using an outreach model the Trust should develop: • culturally appropriate allocation criteria; • systems …
Read more
Four
Derbyshire Mental Health Services NHS Trust
No Response Published
Recommendation
The Trust should take all recent audit findings together with the results of the FACE Risk Profile review to reinforce its risk training programme and to revise their risk management policies and procedures as necessary.
Nine
Derbyshire Mental Health Services NHS Trust
No Response Published
Recommendation
The Trust Being Open Policy should be revised to incorporate a specific section which offers direct guidance to staff regarding the communication and support that should be offered to both victim and perpetrator families following a homicide committed by a …
Read more
One
Derbyshire Mental Health Services NHS Trust
No Response Published
Recommendation
All Trust clinicians should use the formal ICD-10 criteria for making a diagnosis. All decisions and rationales for diagnostic decisions should be clearly recorded in full in the patient clinical record.
Seven
Derbyshire Mental Health Services NHS Trust
No Response Published
Recommendation
The Trust should audit the new clinical supervision policy within six months of the publication of this report to establish the effectiveness of new processes regarding caseload management. The necessary revisions to the policy should then be made in the …
Read more
Six
Derbyshire Mental Health Services NHS Trust
No Response Published
Recommendation
The Trust should commission Phase Two of the Clinical Supervision audit as planned and the findings should be incorporated into any further required revisions of the policy.
Three
Derbyshire City Primary Care Trust
No Response Published
Recommendation
Post Traumatic Stress Disorder assessment and treatment, and trauma focused therapy requirements should be ascertained by the Derbyshire City Primary Care Trust and appropriate commissioning arrangements should be put into place to ensure that specialist services are available to compliment …
Read more
Two
Derbyshire Mental Health Services NHS Trust
No Response Published
Recommendation
All care and treatment plans should follow NICE Guidance where applicable. If this is not possible or clinically indicated then a clear rationale should be provided within the patient clinical record.