Jump to 30 Recommendations

Independent investigation: Maxine Penfold, Cullompton, Devon (2004)

South West
Incident 23 Nov 2004
Subject Maxine Penfold

Paranoid Schizophrenic fatally and repeatedly stabbed mother. Ind Inq 2006. Found poor records and teamwork. Mother sought help two weeks before incident

Report PDF Hundred Families
Acceptance Status
No Response Published 30
Total Recommendations 30
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 (30)

1.1 The Mental Health Trust
No Response Published
Recommendation
Where non-attendance (DNA) occurs, it is brought to the attention of the care co-ordinator, who will risk assess the relevance and develop a carefully thought-through strategy to address this, with colleagues if necessary and preferably in discussion and agreement with … Read more
1.2 The Mental Health Trust
No Response Published
Recommendation
Practitioners involved in the provision of care and treatment have access to, and make use of, a unified and integrated health and social care record-keeping system. This could be ePEX or any other system adopted in the future, which ensures … Read more
1.3 The Mental Health Trust
No Response Published
Recommendation
The record is created and controlled by the practitioners involved, regardless of who enters the information onto the system.
1.4 The Mental Health Trust
No Response Published
Recommendation
Irrespective of how multi-disciplinary (and multi-agency) teams are structured and located, mechanisms are in place to ensure that all practitioners can utilise the above system.
1.5 The Mental Health Trust
No Response Published
Recommendation
Prescribing practitioners ensure that they clearly record medication regimes and if changes occur, the reasons for it. Ref: Guidance on Good Practice, RPS of Great Britain5.
2.1 The Mental Health Trust
No Response Published
Recommendation
Practitioners have access to consistent support mechanisms such as clinical and managerial supervision, mentorship, appraisal and appropriate learning and development opportunities.
2.2 The Mental Health Trust
No Response Published
Recommendation
Multi-disciplinary teams are encouraged to consider a range of evidence-driven treatment and care intervention options.
2.3 The Mental Health Trust
No Response Published
Recommendation
Practitioners and multi-disciplinary teams are required consistently to follow policies and processes for high quality evidence-driven interventions.
3.1 The Mental Health Trust
No Response Published
Recommendation
The sharing of key information concerning patient care. The resolution of complex problems. The formulation of strategic care plans and contingency arrangements. The processing of new referrals. The sharing of achievements and difficulties. Administrative staff to provide documented evidence of … Read more
3.2 The Mental Health Trust
No Response Published
Recommendation
The Trust must ensure that there are robust supervision arrangements, consistently applied.
3.3 The Mental Health Trust
No Response Published
Recommendation
The Mental Health Trust should support robust procedures allowing consultants to meet in peer groups on a regular basis for the purposes of peer supervision. If records are not kept, it would be advisable to do so to ensure targets … Read more
4.1 Commissioners
No Response Published
Recommendation
Ensures the provision is adequate to meet the assessed health and social care needs of a population.
4.2 Commissioners
No Response Published
Recommendation
Enables the resident population to access contemporary services in a timely manner, not influenced by geographical location.
5 The Mental Health Trust
No Response Published
Recommendation
The Mental Health Trust must ensure that wherever carers are actively involved, their statutory rights to a separate assessment of needs should be respected and met.
6.1 The Mental Health Trust
No Response Published
Recommendation
People in receipt of mental health services are placed firmly and unequivocally at the centre of a collaborative and regularly reviewed Care Plan, which is acted upon.
6.2 The Mental Health Trust
No Response Published
Recommendation
All practitioners should receive regular and effective clinical supervision, and have access to a mentor if appropriate.
6.3 The Mental Health Trust
No Response Published
Recommendation
All practitioners, and components of the mental health service are aware of newly developing services, and effectively interface with these, to the benefit of the person in receipt of mental health services.
7.1 The Mental Health Trust and the SHA
No Response Published
Recommendation
The Trust has up-to-date SUI (and other) policies, which all managers and members of staff understand and follow without deviation.
7.10 All stakeholders
No Response Published
Recommendation
All stakeholders should consider how to disseminate the learning from this report.
7.11 Stakeholders with actions arising from this report
No Response Published
Recommendation
In addition to the formal scrutiny to be undertaken by the SHA, those stakeholders with actions arising from this report should consider inviting representatives of the Panel to independently evaluate achievements in 12 months time.
7.2 The Mental Health Trust and the SHA
No Response Published
Recommendation
Members of staff who have been involved in the events immediately prior to an Incident should not be asked to undertake the formal internal review process.
7.3 The Mental Health Trust and the SHA
No Response Published
Recommendation
Issues identified within the Internal process are acted upon, as a matter of urgency across the Trust.
7.4 The Mental Health Trust and the SHA
No Response Published
Recommendation
Future discussion regarding the conduct of ‘Internal’ and ‘Independent’ reviews should not result in an undue delay before potential learning is shared.
7.5 The Mental Health Trust and the SHA
No Response Published
Recommendation
The role of Independent (Homicide) Inquiry Panel members is clear and unambiguous, including any expectations of a facilitation and leadership role.
7.6 The Mental Health Trust and the SHA
No Response Published
Recommendation
The recently issued revised national expectations for Independent Inquiry Panels to use RCA techniques will be incorporated within future Independent (Homicide) Inquiries.
7.7 The Mental Health Trust and the SHA
No Response Published
Recommendation
Arrangements for the attendance of expert assistance to Panels must be considered in advance, and agreed with Panel members.
7.8 The Mental Health Trust and the SHA
No Response Published
Recommendation
There must be a clear and direct line of communication between the Panel and witnesses called.
7.9 The Mental Health Trust and the SHA
No Response Published
Recommendation
Future Inquiries should give consideration to the value of a preliminary ‘stakeholder’ meeting, involving senior officers of the agencies most likely to be providing evidence.
8.1 Partner agencies
No Response Published
Recommendation
Members of staff of all agencies develop a mutual respect for each other’s ways of working.
8.2 Partner agencies
No Response Published
Recommendation
An avoidance of jargon including medical terminology to be encouraged.