Independent investigation: Mayurathy Perinpamoorthy, Yeovil (2013)

When assessing and providing support to patients whose first language is not English, primary and secondary care services must always consider the option of utilising an interpreting service.

Authors of Serious Incident Reports must include evidence within their reports of the methodology that is being utilised within their investigations, for example Root Cause Analysis, a fishbone diagram, 5 Whys.

Authors of Serious Incident Reports must ensure that they are referring to all the relevant NICE guidelines that were in place at the time of the incident.

The Trust’s Safeguarding Adults at Risk Policy should direct practitioners to consider a patient’s culture and ethnicity as being significant and interconnecting factors to both their vulnerabilities and their potential risks of being abused.

The Trust should adopt a universal action plan proforma and ensure that the relevant STEIS incident number is clearly documented on the original and on subsequent action plans.

In order to ensure that all the action plans that have arisen out of this Serious Incident Report have been fully implemented, the Trust should undertake an immediate audit of each recommendation.

In order to evaluate the effectiveness of the new information-sharing systems introduced since this incident, the Trust should consider undertaking an audit exercise of a number of cases, involving similar complex patients, where there is both internal and external multi-agency … Read more In order to evaluate the effectiveness of the new information-sharing systems introduced since this incident, the Trust should consider undertaking an audit exercise of a number of cases, involving similar complex patients, where there is both internal and external multi-agency involvement. Show less

Where it is known that a patient is experiencing financial or housing issues secondary mental health services should be identifying, as part of the patient’s care planning, details of the relevant advocacy and support services and supporting them in accessing … Read more Where it is known that a patient is experiencing financial or housing issues secondary mental health services should be identifying, as part of the patient’s care planning, details of the relevant advocacy and support services and supporting them in accessing such services. Show less

Where static long-term and acute risk factors have been identified as being significant, they must continue to be assessed and documented at this level until such time as it can be evidenced that there has been a significant change in … Read more Where static long-term and acute risk factors have been identified as being significant, they must continue to be assessed and documented at this level until such time as it can be evidenced that there has been a significant change in a patient or that there are new robust protective factors in place. Show less

For the safety and protection of both patients and staff, RiO’s Physical Health Examination pro forma should include a body map that is used, with the patient’s permission, to record any injuries, scars, bruises etc. on a patient’s body. Somerset … Read more For the safety and protection of both patients and staff, RiO’s Physical Health Examination pro forma should include a body map that is used, with the patient’s permission, to record any injuries, scars, bruises etc. on a patient’s body. Somerset Partnership NHS Foundation Trust should introduce the appropriate guidelines regarding the use of body maps. Show less

Both Somerset Partnership NHS Foundation Trust and the recommissioned Somerset Drug and Alcohol Service (SDAS) need to consider developing a specific policy, which includes consideration of the psychological, accommodation and social needs in the provision of services to refugees. Such … Read more Both Somerset Partnership NHS Foundation Trust and the recommissioned Somerset Drug and Alcohol Service (SDAS) need to consider developing a specific policy, which includes consideration of the psychological, accommodation and social needs in the provision of services to refugees. Such a policy should include NICE’s guidelines on supporting such patients with PTSD. Show less

The primary care service involved in this case should familiarise themselves with NICE guidelines regarding the provision of health care to refugee patients.

The Trust’s Risk Assessments and Recovery Care Plans should have a section to indicate if a patient has been involved in the process. The form should also indicate if a patient has agreed with the assessment and if not it … Read more The Trust’s Risk Assessments and Recovery Care Plans should have a section to indicate if a patient has been involved in the process. The form should also indicate if a patient has agreed with the assessment and if not it should be documented what are their reasons. Also the assessment and plan should indicate if the patient has been asked if they would like a copy. Show less

Risk Assessments and Recovery Support plans should always identify and consider a patient’s housing situation. Where a patient is experiencing housing issues, this should be identified and considered as a significant risk factor and one that requires multi-agency intervention and … Read more Risk Assessments and Recovery Support plans should always identify and consider a patient’s housing situation. Where a patient is experiencing housing issues, this should be identified and considered as a significant risk factor and one that requires multi-agency intervention and support. Show less

Somerset Drug and Alcohol Service (SDAS) and Somerset Partnership NHS Foundation Trust must agree a formal information-sharing protocol.