Jump to 42 Recommendations

Independent investigation: Hugh McCaffrey, Willesden

London
Subject Hugh McCaffrey

Mentally ill woman fatally stabbed partner through the heart. Ind Inq 2002 – got 3 years

Report PDF Hundred Families
Acceptance Status
No Response Published 42
Total Recommendations 42
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 (42)

4.77 The Trust
No Response Published
Recommendation
The Trust should ensure that the CPA is fully applied and complied with, and that each patient seen by the secondary services has a key-worker. No patient should be discharged from the secondary services without the benefit of a multi-disciplinary … Read more
4.78 The Trust
No Response Published
Recommendation
Patients who are unwilling or unable to comply with a care plan should be given special consideration and care. Patients who have, in addition to a mental disorder, problems with drugs or alcohol dependency should be able to access appropriate … Read more
4.79 The Trust
No Response Published
Recommendation
Risk assessment should be undertaken in respect of all patients seen by the secondary services. Ideally, this should be on a multi-disciplinary basis and reviewed as often as is appropriate.
4.80 The Trust
No Response Published
Recommendation
Patients seen as unable or unwilling to attend appointments should be afforded greater flexibility and extra efforts should be provided to meet their needs.
4.81 Health Authority and The Trust
No Response Published
Recommendation
Many patients with psychiatric disorders also have significant problems with drugs and alcohol. Appropriate specialist services should be accessible and provided locally.
4.82 The Trust
No Response Published
Recommendation
The Trust should consider the development of assertive outreach teams to access those patients who are seriously ill or unwilling/unable to access the conventional services.
4.83 Prison Medical Services
No Response Published
Recommendation
The prison medical services should maintain close links with the rest of the NHS. Appropriate protocols should be negotiated.
4.84 Prison Medical Services
No Response Published
Recommendation
No inmate should leave prison who has healthcare needs without there having being a full assessment of their needs, and a care plan developed providing for those needs.
4.85 Prison Medical Services and NHS
No Response Published
Recommendation
The therapeutic role of Consultant Psychiatrists visiting prisons for the purposes of assessment of prisoners for forensic purposes should be developed further.
4.86 NHS and Prison Services
No Response Published
Recommendation
Service Agreements should be developed for the role of Consultant Psychiatrists visiting prisons for the purposes of assessment of inmates in order to make reports to courts.
4.87 The Trust, Probation Service and Court Systems
No Response Published
Recommendation
The Trust, Probation Service and court systems should recognise that mentally disordered offenders may have special needs and require diversion from the criminal justice system and that treatment should be a priority.
4.88 Prison Medical Services
No Response Published
Recommendation
Information concerning any mental health assessment and treatment undertaken whilst an individual is a prison inmate should be communicated to that person’s GP and Psychiatrist when that person is discharged from prison.
4.89 Healthcare Services
No Response Published
Recommendation
No patient should be discharged from care or support by any health worker without full prior consultation with that worker's line manger and/or appropriate senior colleague and under the CPA.
5.104 Relevant Key Agencies
No Response Published
Recommendation
Risk assessments should be jointly undertaken between the relevant key agencies with outcomes being formally recorded and shared between these agencies.
5.105 All Agencies (under CPA)
No Response Published
Recommendation
Sharing of this information should be assisted by a multi-agency conference under the CPA pulling together all agencies, identifying information including that of risk and appropriate needs and how the care packages should be delivered via the care plans. Read more
5.106 Health and Social Services
No Response Published
Recommendation
Risk assessments should lead to the development of Risk Management.
5.107 Health and Social Services
No Response Published
Recommendation
A joint Community Mental Health Team should be established under one manager, bringing together Health and Social Services workers.
5.108 Health and Social Services
No Response Published
Recommendation
The team should operate under one Line Manager, with clear, shared eligibility criteria that are well documented and publicised.
5.109 Social Services and Health Authority
No Response Published
Recommendation
Pooled budgets from Social Services and the Health Authority should be considered in order to provide a seamless service, avoid duplication and offer a service within the Best Value framework.
5.110 Social Services and Health Authority
No Response Published
Recommendation
The eligibility criteria should be reviewed in line with available resources. There should be an acknowledgement that vulnerable adults may fall outside the service eligibility criteria and that alternative responses may need to be offered to meet their needs. Read more
5.38 Social Services
No Response Published
Recommendation
Social Services should ensure that the CPA is fully implemented in respect of all cases that meet the Eligibility Criteria.
5.39 Social Services
No Response Published
Recommendation
Social Services should ensure that each case has a clear Care Plan which reflects the assessed individual’s risks and needs, and that the same is reviewed at appropriate intervals by means of multi-agency meetings.
5.40 Social Services
No Response Published
Recommendation
Social Services should ensure clear lines of inter-disciplinary communication before, during and immediately after closure of any case.
5.41 Social Services
No Response Published
Recommendation
Social Services should ensure that closure of a case which falls within the CPA should follow agreed policy and directives.
5.42 All Agencies (under CPA)
No Response Published
Recommendation
No agency should unilaterally terminate their contact with any client who is subject to the CPA without a multi-agency meeting having taken place, a joint agreement reached, and the decision fully recorded.
5.50 Social Services
No Response Published
Recommendation
The Eligibility Criteria should be reviewed in line with available resources. There should be an acknowledgement that vulnerable adults may fall outside such criteria and that alternative responses should be offered to meet their needs.
5.51 Social Services
No Response Published
Recommendation
An Assertive Outreach team should be established available to work with vulnerable people living in the community who are not deemed to be of high enough priority to qualify for an assigned social worker and who yet need support.
5.59 Health and Social Services
No Response Published
Recommendation
The formation of a joint health/social services mental health team under one line manager should be considered.
5.60 Social Services
No Response Published
Recommendation
Social Services should ensure that all Care Plans are well documented and monitored.
5.61 All Agencies
No Response Published
Recommendation
There should be clarity of roles established between all agencies involved in a case. Each agency should have a clear understanding of their respective roles, how they work within a multi-agency team, what protocols exist and what arrangements prevail for … Read more
5.62 Social Services
No Response Published
Recommendation
Social Services should ensure that individual clients and their carers have written information as to how to contact the key worker under CPA and what can be expected of each agency involved in the Care Plan.
5.63 Social Services
No Response Published
Recommendation
Social Services should ensure that the CPA is fully applied and complied with and that each service user seen by the secondary service has a key worker. No service user should be discharged from the secondary services without the benefit … Read more
5.66 Social Services
No Response Published
Recommendation
Social Services should have an agreed policy on what information can be shared between different divisional social workers working with different members of the same family and ensure that the database is cross-referenced to identify other divisional workers’ involvement in … Read more
5.70 Social Services
No Response Published
Recommendation
Social Services should ensure through the use of the CPA that all agencies are aware of each others’ contributions to Care Plans.
5.76 Brent Social Services
No Response Published
Recommendation
Brent Social Services should ensure that when writing a Vulnerability Report, it is an accurate reflection of the situation. Inflation of individuals’ problems should not occur.
5.77 Social Services
No Response Published
Recommendation
When submitting a Vulnerability Report, Social Services should ascertain whether the individual had afterwards presented themselves to the Housing Department’s Homeless Unit.
5.78 Social Services
No Response Published
Recommendation
A copy of the Vulnerability Report should be sent directly to the Homeless Unit to alert it to pending requests for help.
5.79 Housing and Social Services
No Response Published
Recommendation
Through joint planning and the development of the housing resource base, there should be greater clarity as to the accommodation needs of vulnerable adults living in the community.
5.87 All relevant agencies (drug and alcohol rehabilitation services)
No Response Published
Recommendation
Care Plans prepared for clients needing to use the drug and alcohol rehabilitation services should clearly identify users’ assessed needs and the availability of the services which will need to be accessed and such should be noted on an accessible … Read more
5.88 Managers of all relevant agencies and Health Authority
No Response Published
Recommendation
Managers of all relevant agencies should be made aware of the rehabilitation services purchased by the Health Authority, their availability, eligibility criteria and how to access the same.
5.96 Social Service Departments (Senior or middle managers)
No Response Published
Recommendation
Senior or middle managers in the Social Service departments should actively monitor the number of failed appointments between services users and relevant agencies in order to evaluate whether the adopted approach is appropriate or should be altered. All decisions taken … Read more
5.97 All Agencies
No Response Published
Recommendation
All agencies should have a clear understanding with regard to implementing the eligibility criteria for accessing respective services, and for identifying measurable outcomes.