Jump to 27 Recommendations

Independent investigation: John Redhead, Potters Bar (2007)

East of England
Incident 26 Aug 2007
Subject John Redhead

Mental health patient convicted of murdering ex boyfriend. Drug user. Ind inq. 2013 Niche

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 The Trust
No Response Published
Recommendation
The Trust should review the processes in place for ensuring that details of service users’ addresses on Trust information systems are up to date.
10 The Trust
No Response Published
Recommendation
The Trust should review the processes in place for responding to service users and carers reporting crisis situations to the CMHT, and develop guidance and policy for clinicians detailing the appropriate care pathways that should be used to ensure risk … Read more
11 The Trust
No Response Published
Recommendation
The Trust should ensure that communication and referral pathways between CATT’s, CMHT’s and inpatient services are clear and auditable and are understood by all relevant clinical staff.
12 The Trust
No Response Published
Recommendation
The Trust should ensure that clinicians and managers are aware of the appropriate pathway and referral routes for inter team referrals, and develop interface agreements between services which will then clarify the movement of service users between teams. Read more
13 The Trust
No Response Published
Recommendation
The Trust should put processes in place to ensure that inter team and service referrals are acknowledged on receipt, and that any referrals not acknowledged are followed up by the referrer.
14 The Trust
No Response Published
Recommendation
The Trust should ensure that all clinicians working in mainstream mental health services receive awareness training on the management of people with personality disorders and the thresholds for involvement of the specialist team.
15 The Trust
No Response Published
Recommendation
The Trust should ensure that future risk assessment training for all clinicians must also include the exploration of ‘near misses’ or serious and violent incidents that could have led to severe harm as an outcome but didn’t.
16 The Trust
No Response Published
Recommendation
The Trust should ensure that there is a robust process in place to ensure the appropriate retention and storage of records and ensure there is a tracking procedure in place so that the whereabouts of original paper clinical records and … Read more
17 The Trust
No Response Published
Recommendation
The Trust should ensure that all clinical and admisistrative staff have received training in their responsibilities regarding the administration of clinical records and that the content of such training contains all aspects contained within the NHS Code of Practice and … Read more
18 The Trust
No Response Published
Recommendation
A high level discussion between the Trust and local police needs to take place to agree to implement the components outlined within the Memorandum of Understanding10.
19 The Trust
No Response Published
Recommendation
The Trust should ensure that senior managers and Trust directors are aware of their responsibilities outlined within the Memorandum of Understanding11 and these should be made explicit within Trust policy.
2 The Trust
No Response Published
Recommendation
Where alternative communication mechanisms and technologies are used to communicate with, and inform, service users of appointments, the efficacy of these should be evaluated.
20 The Trust
No Response Published
Recommendation
The Trust should ensure that there are evidence based and auditable processes in place to quality check the outcome of Serious Untoward Incident Investigations.
21 The Trust
No Response Published
Recommendation
The Trust Serious Untoward Incident Investigation should be robust and thorough with identified learning points, a robust action plan that is carefully monitored by the Trust Board.
22 The Trust Board
No Response Published
Recommendation
The Trust Board should confirm and challenge the outputs from the reports and the actions arising.
23 The Trust
No Response Published
Recommendation
The Trust should undertake a review to examine the efficacy of the processes in place for the learning and sharing of lessons learned to establish their efficacy.
24 The Trust
No Response Published
Recommendation
The Trust should ensure that one of the functions of the Incident Co-ordination Group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way.
25 Commissioners
No Response Published
Recommendation
Commissioners should undertake a review of the provison of psychological therapies within the relevant GP surgery to ensure that practice, referral and uptake rates are consistent with national standards.
26 The Trust
No Response Published
Recommendation
The Trust should ensure that wards and CMHT’s work together and formally agree CPA and aftercare arrangements for service users prior to their discharge from hospital.
27 The Trust
No Response Published
Recommendation
The Trust should ensure that the requirements of CPA are fulfilled for service users who are only seen as outpatients by Consultant Psychiatrists and their medical teams.
3 The Trust
No Response Published
Recommendation
The Trust should ensure that all eligible carers receive a carers assessment.
4 The Trust
No Response Published
Recommendation
The Trust should ensure that there are standards and a formal process in place to ensure the completion and retention of minutes of all meetings that take place in community teams, when current, past, or potential service users are discussed … Read more
5 The Trust
No Response Published
Recommendation
When a service user does not have a Care Co-ordinator identified, the Trust should ensure that there is a clinician identified at each CPA review or discharge planning meeting who will take responsibility for ensuring that all actions and referrals … Read more
6 The Trust
No Response Published
Recommendation
An audit of CPA reviews and discharge planning meetings, for service users currently receiving care under CPA, should take place to ascertain that all actions and referrals deemed necessary have been acted upon and completed in full.
7 The Trust
No Response Published
Recommendation
The Trust should ensure there is guidance available to clinicians outlining criteria and standards that should apply for service users who are discharged from inpatient units in their absence, and ensure that compliance with this is audited within three months … Read more
8 The Trust
No Response Published
Recommendation
The Trust should ensure that there is a formal, auditable process in place that ensures referrals from Crisis Assessment and Treatment Team (CATT) to CMHT’s are forwarded, acknowledged and responded to on an urgent basis.
9 The Trust
No Response Published
Recommendation
Clinicians working within CATT should be made aware of their responsibility to monitor service users, where a need has been identified for an alternative plan of care from a CMHT, until the CMHT have acknowledged receipt of the referral.