Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005)

Northern Ireland

Incident 12 Jul 2005

Subject Lauren O’Neill

MH homicide of daughter and herself. Ind Inq found catalogue of errors and missing notes

Report PDF Hundred Families

Acceptance Status

No Response Published 36

Total Recommendations 36

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 (36)

1 Belfast City Hospital, South and East Belfast Trust and Foyle Trust

No Response Published

Recommendation

Belfast City Hospital, South and East Belfast Trust and Foyle Trust should review their arrangements for multidisciplinary working and information sharing focusing on: - roles - the nature of services - treatments and interventions - structures - accurate targeting of … Read more

10 Counselling bodies

No Response Published

Recommendation

Counselling bodies should make child protection training including refresher training a mandatory component of ongoing registration.

11 Counselling bodies

No Response Published

Recommendation

Counselling bodies should require counsellors registered with them to follow the Department’s Child Protection Policy ‘Co-operating to Safeguard Children’ and Regional ACPC Policies and Procedures.

12 DHSSPS and four ACPCs

No Response Published

Recommendation

DHSSPS should review Co-operating to Safeguard Children and the four ACPCs should review their Child Protection Policy and Procedures to ensure that both documents provide consistent and specific guidance for counsellors and psychotherapists, particularly those working in a private capacity. Read more

13 DHSSPS

No Response Published

Recommendation

The DHSSPS should, in conjunction with the Department of Employment and Learning and education providers, review all undergraduate and post graduate training for relevant professions to include a core understanding of child protection issues.

14 Trusts

No Response Published

Recommendation

Trusts should ensure that all SHOs new to Psychiatry should have an induction course covering role clarification and a basic knowledge of common psychiatric disorders, their treatment and management.

15 Trusts

No Response Published

Recommendation

Trusts should ensure that multidisciplinary staff are aware of the nature of therapeutic relationships and the concepts of transference and counter-transference.

16 Trusts

No Response Published

Recommendation

Trusts should ensure that staff working in the field of mental health have continuous professional development plans which include in-service training and evidence based practice refresher courses.

17 DHSSPS and Boards

No Response Published

Recommendation

DHSSPS and Boards should ensure that each Trust puts in place a joint protocol designed to manage the interface between mental health and child care services, addressing and facilitating the co-working of cases where there are concerns that adult mental … Read more

18 four ACPCs

No Response Published

Recommendation

The four ACPCs should jointly commission multidisciplinary training across the region for mental health and child care staff, focused on working together in cases where there are adults with mental health issues who have dependent children. This training must explicitly … Read more

19 DHSSPS

No Response Published

Recommendation

DHSSPS should ensure that consideration of parental mental health is integrated into all stages of the new Northern Ireland Assessment Framework for Children. (Understanding the Needs of Children in Northern Ireland).

2 South and East Belfast Trust

No Response Published

Recommendation

South and East Belfast Trust should review its arrangements for admitting patients for in-patient care, with particular reference to a daily waiting list management and bed management system and an ongoing contact system with patients and their carers when beds … Read more

20 South and East Belfast Trust

No Response Published

Recommendation

South and East Belfast Trust should review the assessment models used by CRT and FCC IAT in cases where a parent with dependent children has attempted suicide or made a serious threat of self-harm.

21 DHSSPS

No Response Published

Recommendation

DHSSPS should develop guidance that would lead to the implementation of consolidated assessments in mental health. Consolidated assessment would underpin improvements in risk assessment, key working/case co-ordination, multidisciplinary working, care planning and discharge planning which all feature in other recommendations … Read more

22 Boards and Trusts

No Response Published

Recommendation

Boards and Trusts must ensure that supervisory policies are in place which require that: - Arrangements are in place to monitor and audit assessment, case management, effectiveness of interventions, record keeping and discharge planning of individual cases. - Staff understand … Read more

23 DHSSPS

No Response Published

Recommendation

DHSSPS should review guidance in relation to care planning. The review should ensure that care plans are designed in conjunction with a model of care and include consideration of risk assessment and management, multidisciplinary working, verifying information provided by the … Read more

24 SEB and Foyle Trusts, DHSSPS

No Response Published

Recommendation

Both SEB and Foyle Trusts should undertake urgent reviews of their systems for developing discharge plans for patients leaving their hospitals. In addition DHSSPS should consider providing guidance in relation to discharge planning. The basic elements which should form part … Read more

25 Boards and Trusts

No Response Published

Recommendation

Boards and Trusts must ensure that each in-patient unit has a bed management policy in place, which outlines the bed management system and identifies an accountable named individual.

26 South and East Belfast and Foyle Trusts

No Response Published

Recommendation

Both South and East Belfast and Foyle Trusts should have in place as part of their governance arrangements a system to monitor and audit case records within Mental Health services to ensure: - Accuracy - Assessment and management of risk … Read more

27 DHSSPS in co-operation with responsible Departments in Great Britain

No Response Published

Recommendation

DHSSPS in co-operation with responsible Departments in Great Britain should implement its commitment to the statutory registration and regulation of psychotherapists and counsellors as outlined in the 2006 consultation on standards. The associated guidance to psychotherapists and counsellors should aim … Read more

28 DHSSPS and Boards

No Response Published

Recommendation

DHSSPS and Boards should ensure that Trusts have a policy in relation to identifying and recording ‘Next of Kin’ information. Trusts should also consider the extent to which staff training and/or refresher training should be provided for front-line staff involved … Read more

29 DHSSPS, Trusts

No Response Published

Recommendation

Whilst acknowledging the planned benefits in ‘Protect Life – A Shared Vision’ – The Northern Ireland Suicide Prevention Strategy and Action Plan, 2006-2011 launched in October 2006, including its stated intention to provide support and assistance to families bereaved by … Read more

3 Foyle Trust

No Response Published

Recommendation

Foyle Trust should review its arrangements for admitting patients for in-patient care to Gransha to ensure in particular that SHOs obtain all relevant background information from the referring GP or hospital and collateral information from the patient’s family, as far … Read more

30 DHSSPS

No Response Published

Recommendation

In light of the circumstances leading up to the deaths of Madeleine and Lauren, the DHSSPS should request CREST or its successor organisation to urgently review its August 2006 Protocol relating to inter-hospital transfer of mental health patients, with a … Read more In light of the circumstances leading up to the deaths of Madeleine and Lauren, the DHSSPS should request CREST or its successor organisation to urgently review its August 2006 Protocol relating to inter-hospital transfer of mental health patients, with a view to including: - A section dealing with Child Protection issues (perhaps along the lines of the Child Protection section in the Protocol document drawn up by South and East Belfast Trust [Knockbracken Mental Health Services – Treatment Services] in November 2006) (Appendix 3). - A specific statement that if transfers of patients are carried out by or with relatives and their personal transport, the patients’ records must be transferred separately from the patient and relatives, by secure means. - A specific statement that transfers of patients must always require pre-move written data setting out core features of the illness, diagnosis and reasons for the transfer, to be faxed or emailed in keeping with approved confidentiality arrangements, in advance to the receiving hospital, and agreed in writing by the accepting Consultant, prior to the actual move. - Guidance to Trusts on definition and use of the words ‘transfer’ and ‘discharge’ in the context of movement of a patient from one psychiatric hospital to another in the province with no intention of the patient returning to the referring hospital, given the apparent interchangeable use of the two words in relation to the movement of Madeleine O’Neill from Knockbracken to Gransha Hospital. When this further updated CREST protocol is available it should be issued by the DHSSPS to Trusts for implementation as a standard protocol throughout the service in Northern Ireland, rather than as guidance for the preparation of protocols by each individual Trust. In addition, within 6 months of issue of CREST’s updated protocol, the DHSSPS should require Trusts to provide evidence of specific action undertaken to make relevant staff aware of the updated protocol, the need to adhere to it strictly and the need to formally review the working of the updated protocol at regular intervals of not more than one year. Show less

31 DHSSPS

No Response Published

Recommendation

DHSSPS should ensure that when guidance is issued for implementation by the HPSS on particular service issues, an audit mechanism is included to ensure that the required action is taken within a specified timescale.

32 DHSSPS

No Response Published

Recommendation

There are clearly continuing issues of understanding and interpretation of some aspects of the 2004 Guidance apparent within Trusts and the medical profession, (as expressed by the NI Branch of the Royal College of Psychiatrists), which contributed in some measure … Read more

33 DHSSPS, Boards, Trusts and other relevant bodies such as the Mental Health Commission and ACPCs

No Response Published

Recommendation

Steps should be taken by the DHSSPS, in conjunction with Boards, Trusts and other relevant bodies such as the Mental Health Commission and ACPCs, to draw up and issue guidance regarding the production of initial investigation reports by Trusts, in … Read more

34 DHSSPS

No Response Published

Recommendation

We fully endorse and support the recommendation of the Inquiry Panel (McCleery) and the guidance in ’Co-operating to Safeguard Children’. In light of events in this case, the DHSSPS should issue further formal guidance / instructions to all Trusts in … Read more

35 DHSSPS in collaboration with corresponding Departments in England, Wales and Scotland

No Response Published

Recommendation

DHSSPS in collaboration with corresponding Departments in England, Wales and Scotland should commission UK wide research into all aspects of child killing to ensure that attention is given to increasing the understanding of cases involving parents who are mentally disordered … Read more

36 DHSSPS and Boards

No Response Published

Recommendation

When commissioning inquiries DHSSPS and Boards should ensure that inquiry panels have early access to research and similar inquiries of which DHSSPS and/or Boards are aware. This would avoid duplication of effort and support the learning objectives of inquiries. Read more

4 DHSSPS and the Boards

No Response Published

Recommendation

The DHSSPS and the Boards should instruct Trusts to draw up and implement policies regarding consultation by staff with patients’ families during an in-patient stay, in particular at admission, discharge and where the patient has a dependent child or children. Read more

5 Trusts

No Response Published

Recommendation

Trusts should ensure that there is clarity in the role and function of Crisis Response Teams, Home Treatment Services and Community Mental Health Teams.

6 Trusts

No Response Published

Recommendation

Trusts should ensure that there are sound arrangements for clinical supervision within Community Teams in general and specialist advice/support in Community Home Treatment and Crisis Response Team services. In constructing these arrangements Trusts should be aware that increasing specialisation of … Read more

7 Trusts

No Response Published

Recommendation

Trusts should ensure that protocols for discharging patients from a service should be clear and should include the principle of informing the referral agent, the patient’s GP and other professional colleagues involved in the care of the patient.

8 Boards and Trusts

No Response Published

Recommendation

All Boards and Trusts should review the child protection training and awareness of all staff, including access to policies and procedures.

9 DHSSPS in conjunction with Boards’ ACPCs

No Response Published

Recommendation

DHSSPS in conjunction with Boards’ ACPCs should review the content and uptake of child protection training delivered to GPs and should consider making such training mandatory for all relevant staff and practitioners.