Jump to 38 Recommendations

Independent investigation: John Curran, Highbury & Islington (2006)

London
Incident 07 Jul 2006
Subject John Curran

Schizophrenic fatally pushed stranger in front of a tube train, two weeks after telling Drs. Ind Inq 2010. Vol. Homerton patient.

Report PDF Hundred Families
Acceptance Status
No Response Published 38
Total Recommendations 38
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 (38)

R1 East London NHS Foundation Trust
No Response Published
Recommendation
The current model of working between the consultants and specialist registrars should be further examined by the trust to ensure that there is an explicit, single line of consultant responsibility throughout a patient’s inpatient stay and that responsibility is retained … Read more
R10 East London NHS Foundation Trust
No Response Published
Recommendation
Each consultant should review only their own patients during their ward rounds (unless covering the leave of another consultant).
R11 East London NHS Foundation Trust
No Response Published
Recommendation
Both consultant psychiatrist A and B should examine how the added value of one-to-one assessments would improve their clinical decision-making, the rationale for when such assessments would be appropriate in individual cases and how undertaking such assessments could be incorporated … Read more
R12 East London NHS Foundation Trust
No Response Published
Recommendation
Consultants should supervise what is recorded in the notes.
R13 East London NHS Foundation Trust
No Response Published
Recommendation
Trainee doctors should receive structured training on how to record discussions in ward rounds in particular and what to write in the notes in general.
R14 East London NHS Foundation Trust
No Response Published
Recommendation
An explicit management plan should be recorded in the notes at each ward round, including treatment and non-medical interventions proposed and risk management.
R15 East London NHS Foundation Trust
No Response Published
Recommendation
The discharge summary should refer to and be accompanied by the risk assessment and management tools when sent to the GP, or include specific sections addressing the risk assessment and management for that individual.
R16 East London NHS Foundation Trust
No Response Published
Recommendation
Doctors who have not been involved with a patient’s care should not prepare that patient’s discharge summaries.
R17 East London NHS Foundation Trust
No Response Published
Recommendation
Drug screening must be systematically and routinely carried out on any patient suspected of using illicit drugs.
R18 East London NHS Foundation Trust
No Response Published
Recommendation
The implications of a negative drug screen when a positive screen was expected should be noted.
R19 East London NHS Foundation Trust
No Response Published
Recommendation
The liaison between Conolly ward and the community teams must be examined and improved, with clear records of attendance of community team members at ward-based meetings, CPA reviews and ward rounds and their involvement in and contribution to such meetings … Read more
R2 East London NHS Foundation Trust
No Response Published
Recommendation
Consultant psychiatrist B’s specialist registrar should not make decisions on behalf of consultant psychiatrist A.
R20 East London NHS Foundation Trust
No Response Published
Recommendation
Clinical and management decisions made by the SELT should be contributed to and endorsed by the relevant consultant.
R21 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should clarify the role of the home treatment team.
R22 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should ensure that the home treatment team is adequately resourced and able to operate to reduce or abolish over-occupancy, to provide a safer and more appropriate alternative to the use of unescorted leave and to provide a gate-keeping … Read more
R23 East London NHS Foundation Trust
No Response Published
Recommendation
The relationship and communication between the home treatment team and inpatient service must be made more explicit so as to allow the home treatment team to undertake its roles as a psychiatric emergency community assessment and treatment service, an alternative … Read more
R24 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should review its CPA guidance in light of the new Department of Health guidance on CPA1, the findings of the internal investigation report and this investigation. It should pay particular attention to ensuring care planning and risk assessments … Read more
R25 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should ensure a broad view of a patient’s past history forms part of any risk assessment and that there should not be undue reliance on whether the person has been violent or has self-harmed as a predictor of risk.
R26 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should not rely solely on issuing new policies but provide opportunities for all senior clinicians and managers to understand fully and commit to the principles underpinning CPA. The objective of the training should be to avoid a superficial … Read more
R27 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should ensure that all staff comply with its policies on CPA, risk assessment and risk management regardless of their own personal views.
R28 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should ensure that CPA policies and procedures stress the importance of planning for and managing transitions. Advocacy services should be available for all patients when major changes are introduced to their care to ensure that they understand what … Read more
R29 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should amend its existing child protection policies and procedures so that they explicitly cover circumstances in which someone with a mental illness is living in the same house as a child.
R3 East London NHS Foundation Trust
No Response Published
Recommendation
Where one consultant takes over the care of a patient from another, such a handover must be documented in the medical records.
R30 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should ensure that all staff are familiar with child protection procedures and understand how to operate them. The trust should audit compliance.
R31 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should continue to review how they could develop a service for the 16 to 25 age group which would overlap with CAMHS and adult services rather than be separate from them.
R32 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should develop a process for ensuring a full family history is always taken and that assumptions are always checked in relation to the culture of the particular patient.
R33 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should ensure that interpreters are used when necessary, especially where there may be language difficulties for a primary carer.
R34 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should undertake a review of the dependency needs of the clients on Conolly ward and the appropriate staffing to meet those needs. The review should be undertaken collaboratively with the staff on the ward and any changes made … Read more
R35 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should review the patient leave policy and procedures on Conolly ward as a matter of urgency to ensure that the current practice is safe and compliant with CPA.
R36 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should ensure reflective practice/learning opportunities are always arranged and supported after a serious untoward incident so that individuals can take responsibility for their own learning.
R37 East London NHS Foundation Trust
No Response Published
Recommendation
The trust’s policy on management of incidents should be amended to include: • in what circumstances staff may be relieved of their duties after a serious untoward incident; the status of their absence and their rights regarding representation; • the … Read more
R38 East London NHS Foundation Trust
No Response Published
Recommendation
The trust should amend its policy on managing incidents to ensure it clearly separates out policy, procedure and guidance and to improve its readability.
R4 East London NHS Foundation Trust
No Response Published
Recommendation
Consultants can still provide second opinions but these should be identified clearly as such in the notes.
R5 East London NHS Foundation Trust
No Response Published
Recommendation
Trainee doctors working in psychiatry in the trust should receive formal training in the role of CPA and risk assessment.
R6 East London NHS Foundation Trust
No Response Published
Recommendation
If consultant psychiatrist A is not approved as a trainer for junior doctors, he should receive alternative ward-based medical support to help him manage his allocated inpatients.
R7 East London NHS Foundation Trust
No Response Published
Recommendation
Consideration should be given by the trust to having a non-medical individual with the requisite seniority, such as ward manager or senior occupational therapist chair the Monday management meeting, CPA reviews or ward rounds.
R8 East London NHS Foundation Trust
No Response Published
Recommendation
The role and purpose of the Monday management round and Friday “putting to bed” round should be evaluated and clarified by the trust.
R9 East London NHS Foundation Trust
No Response Published
Recommendation
Clinical decisions should not be made in the Monday management round.