Jump to 27 Recommendations

Independent investigation: Jim Ward, Ayr (2007)

Scotland
Incident 07 Jun 2007
Subject Jim Ward

Paranoid Schizophrenic fatally and repeatedly stabbed father. Ind Inq 2009. Family warnings

Report PDF Hundred Families
Acceptance Status
No Response Published 27
Total Recommendations 27
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 (27)

1 NHS Board A
No Response Published
Recommendation
NHS Board A must critically review their model of care for people with dual diagnosis. This must include explicit consideration of whether a model of providing shared care between addiction services and general adult services would offer more safeguards than … Read more
10 NHS Board A
No Response Published
Recommendation
NHS Board A must put procedures in place that ensure that staff properly re-examine the home environment at key points in the care process. This must include documented consultation with carers and other people living in that environment.
11 NHS Board A and SWD1
No Response Published
Recommendation
NHS Board A and SWD1 must ensure that where teams do not have integrated social work provisions there is clear guidance as to why, how and when services can be accessed.
12 NHS Board A and SWD1
No Response Published
Recommendation
NHS Board A and SWD1 must ensure that all workers involved in the Mr F case receive refresher training in child protection issues. They should also consider whether this may equally applicable to the rest of their workforce.
13 NHS Board A and SWD1
No Response Published
Recommendation
NHS Board A and SWD1 must ensure that the Care Programme Approach (CPA) is being used in line with its own current guidelines.
14 NHS Board A and SWD1
No Response Published
Recommendation
NHS Board A and SWD1 should look to reviewing their agreed, shared risk assessment process. While the documentation to assist this is clearly established, documentation alone does not ensure the accurate recording of information or help individual professionals or groupings … Read more
15 NHS Board A and SWD1
No Response Published
Recommendation
NHS Board A and SWD1 must give serious consideration to extending or clarifying CPA criteria to ensure that this process is put in place for any individual experiencing persistent psychotic symptoms or other factors which indicate elevated risk to others. Read more
16 NHS Board A and SWD1
No Response Published
Recommendation
Where risk involves someone to whom the patient has access, there must be a detailed assessment of that risk. Where families form an integral part of a patient’s life, the findings must be shared with the family in order that … Read more
17 SWD1
No Response Published
Recommendation
Where the risk involves a family member to whom the patient has access, SWD1 must ensure that a carers needs assessment is undertaken and that this is properly considered as an integral part of the original care plan.
18 SWD1
No Response Published
Recommendation
SWD1 must put in place a system where staff absence does not result in cases being left for prolonged periods without review or intervention.
19 SWD1
No Response Published
Recommendation
SWD1 must ensure that an assessment of need is undertaken in line with the Social Work (Scotland) Act 1968 and Community Care and Health (Scotland) Act 2002 at the point of initial contact with the service.
2 NHS Board A
No Response Published
Recommendation
If NHS Board A decides to continue with their current model, there must be a documented discussion on admission and again at discharge to set out the purpose of admission, develop an agreed treatment plan and proactively plan aftercare. Use … Read more
20 SWD1 and NHS Board A
No Response Published
Recommendation
SWD1 and NHS Board A must ensure that all workers involved in the Mr F case receive refresher training in the systems and processes involved in the single shared assessment process and their role in it.
21 NHS Board A and SWD1
No Response Published
Recommendation
NHS Board A and SWD1 must give serious consideration to the structures in place to support a co-ordinated approach to the delivery of a multi-disciplinary care package. The Care Programme Approach, for example, ensures active participation of all relevant parties, … Read more
22 SWD1 and NHS Board A
No Response Published
Recommendation
SWD1 and NHS Board A must ensure that where services are commissioned, the service provided is scrutinised by the commissioner and reviewed regularly to ensure that the particular service remains appropriate to the assessed needs of the individual.
23 NHS QIS
No Response Published
Recommendation
NHS QIS should develop and oversee the implementation of a standardised process for critical incident reviews (CIRs) for use across all mental health services in NHS Scotland.
24 NHS Board A
No Response Published
Recommendation
Until NHS QIS guidance is available NHS Board A must, as a matter of urgency, develop and implement policy governing CIRs. This should include direction with regard to when CIRs are required; who should be involved; the expertise of the … Read more
25 NHS Board A
No Response Published
Recommendation
The Chair of any CIR must be, and be seen to be, independent to the service, have appropriate training in conducting CIRs and have expert knowledge of the subject area being reviewed.
26 NHS Board A
No Response Published
Recommendation
There must be clear splitting off of the function of staff support/debrief from an exacting examination of the facts. NHS Board A should develop guidance to issue to staff involved in CIRs to ensure that they are fully aware of … Read more
27 The Scottish Government
No Response Published
Recommendation
The Scottish Government should commission a review of the current use of CPA in Scotland with a view to establishing patterns of use across different regions and the quality of the processes being used. Where problems are identified, steps should … Read more
3 NHS Board A
No Response Published
Recommendation
If NHS Board A continues with a separate DDT service, NHS Board A must define the criteria/point at which patients are moved on to general adult services, ensure that patients are moved on from the DDT to general adult services. … Read more
4 NHS Board A
No Response Published
Recommendation
NHS Board A should review the care and treatment of patients currently receiving treatment from the dual diagnosis team to ensure that their mental illness needs are being adequately treated.
5 NHS Board A
No Response Published
Recommendation
NHS Board A must examine the availability of clinical pharmacy support to all mental health teams and this should include reference to current good practice guidance on the use of licensed medicines for unlicensed applications (Royal College of Psychiatrists CR142) Read more
6 NHS Board A
No Response Published
Recommendation
NHS Board A must address the clinical psychology provision to in-patient services and to small specialist teams such as the DDT. This provision should be of a level which allows the assessment and treatment of the most complex cases and … Read more
7 NHS Board A
No Response Published
Recommendation
NHS Board A must ensure that all teams have access to expertise in psychological assessment – including risk assessment – in order to maximise the likelihood of the correct intervention being used. Many psychological interventions, including structured family interventions, can … Read more
8 NHS Board A
No Response Published
Recommendation
NHS Board A must ensure that all staff are aware of the relationship between family environments and relapse in psychosis.
9 NHS Board A
No Response Published
Recommendation
NHS Board A must ensure that all teams dealing with people with severe and enduring mental health problems have access to evidence-based family interventions. Where teams are viewed as too small in their own right to support a worker trained … Read more