Independent investigation: Nicole TownshendJane Malkin, Leicester (2007)

Midlands

Incident 30 Jan 2007

Subject Nicole TownshendJane Malkin

Psychotic drives car and mounts pavement killing two strangers (Satan driving). Sought help day before but released, Ind Inq

Report PDF Hundred Families

Acceptance Status

No Response Published 9

Total Recommendations 9

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 (9)

1 Executive Director of Quality & Innovation, Director of Risk Assurance, and Service Manager for LPT crisis resolution teams.

No Response Published

Recommendation

LPT needs to ensure that its crisis resolution and home treatment professionals have access to up-to-date and appropriate clinical records when conducting emergency mental health assessments. At the time this MHSU was receiving home treatment the CRHT did not have … Read more

2 LPT’s Chief Operating Officer, Service Manager for LPT crisis resolution teams (city and county).

No Response Published

Recommendation

The operational policy for LPT’s crisis resolution and home treatment service must set out clear and measurable standards for how service users are discharged. The crisis resolution and home treatment operational policy must set out clearly the standards expected when … Read more

3 Executive Director of Quality & Innovation, Director of Risk Assurance, and Service Manager for LPT crisis resolution teams.

No Response Published

Recommendation

LPT’s crisis resolution and home treatment service must ensure that its discharge summaries provide complete information to GPs and other relevant mental health teams and agencies. The information provided on the discharge summaries from the CRHT to GPs and other … Read more

4 LPT’s Chief Executive, Executive Director of Quality & Innovation, Director of Risk Assurance.

No Response Published

Recommendation

LPT must ensure that up-to-date and appropriate clinical records are available to staff conducting emergency mental health assessments. Although home treatment is for relatively short periods of time, if it subscribes to the concept of “one patient, one set of … Read more

5 Executive Director of Quality & Innovation, Director of Risk Assurance, and Service Manager for LPT crisis teams.

No Response Published

Recommendation

The LPT crisis resolution and home treatment service needs to minimise the loss of information along the communication pathway from those making referrals to the assessing mental health practitioners. This investigation highlights the dangers of introducing too many variables in … Read more The LPT crisis resolution and home treatment service needs to minimise the loss of information along the communication pathway from those making referrals to the assessing mental health practitioners. This investigation highlights the dangers of introducing too many variables in a communication pathway when service users are referred for assessment by the CRHT. In this case, information from the deliberate self harm (DSH) team was passed verbally to a triage nurse who made notes of the discussion, which were then provided to the mental health professionals (MHPs) asked to assess the service user. There was a loss of important information during this process. Consequently it is the recommendation of the IIT that: A faxable referral form is developed for the CRHT which provides clear headings for entering specific information. It should have an accompanying guidance sheet detailing its purpose and how it will be used. All future referrals to the CRHT should be made, or confirmed, in writing on this form. All faxed referrals are supplemented with telephone follow up by the CRHT triage nurse, or preferably the mental health professionals tasked with undertaking any subsequent assessment. For the deliberate self harm (DSH) assessment form to be extended so that greater detail about the assessment can be recorded. This should include full details of any discussions the DSH team has with a service user’s regular care team and the outputs of this. If a DSH MHP believes admission to be the only option at the time of their assessment, this should be made explicit at the time of referral so that this perspective is clear to the next team, who may not be conducting their assessment until sometime later. Consequently consideration needs to be given to ensuring that a prompt for this opinion is included on any revision of the DSH assessment form. The DSH assessment form needs to record the contact numbers for the assessing DSH professionals, so that the assessing CRHT MHP can make proactive communication with this team. Indeed LPT could explore the practicalities of expecting the assessing CRHT MHP to have a direct conversation with the referrer prior to their assessment rather than this solely being undertaken by the CRHT triage nurse. This would reduce the opportunity for miscommunication, misinterpretation of information, and information loss. The current draft (July 2010) of the revised crisis and home treatment team operational policy does not fully address this recommendation, and the wording over whether or not telephone referrals will be routinely accepted is less than clear. It currently implies that telephone referrals will be acceptable. It is the recommendation of the IIT that the normal standard of practice should be for faxed referrals, followed up by telephone communication, in all but exceptional circumstances. Show less

6 Executive Director of Quality & Innovation, Director of Risk Assurance, the lead clinician for the crisis resolution and home treatment service, and Service Manager for LPT crisis teams.

No Response Published

Recommendation

All crisis resolution and home treatment professionals in LPT must recognise the increased accountability they accept when they elect not to seek the advice of the on-call psychiatric team when undertaking out of hours assessments. A culture of not using … Read more All crisis resolution and home treatment professionals in LPT must recognise the increased accountability they accept when they elect not to seek the advice of the on-call psychiatric team when undertaking out of hours assessments. A culture of not using available medical input out of hours has no place in the delivery of an effective and safe crisis resolution and home treatment service. The IIT has formed the view that it is not customary for crisis resolution and home treatment professionals to seek medical input into their out of hours crisis assessments where these are conducted on hospital premises, most usually A&E. It is essential that all crisis resolution and home treatment MHPs understand that their accountability and responsibility for a service user commences at the point they make the decision to accept this service user for home treatment, and that it is at this point that a care and treatment package, even if this is a short term package, needs to be agreed between the assessing professionals and the service user. In this case the MHPs did agree with the service user that she was to stay at home until assessed by a consultant psychiatrist the following morning. This was however an inadequate plan for this service user. To assist MHPs in accurately recording their rationale for any treatment options instituted or not instituted, the IIT considers that it is important that the crisis team assessment tool prompts the assessing MHPs to record the immediate care and treatment agreement/contract agreed with the service user. Where this is out of hours and there is no liaison with available medical practitioners (registrar grade and above), then the reason for this should also be recorded. Similarly, where it is considered that medication is not necessary the rationale for this should also be recorded. The design of the assessment tool should reliably remind crisis resolution and home treatment professionals of the need for this information. The IIT has formed the view that one of the reasons that CRHT MHPs may not be accessing medical advice out of hours is because of the variability of response they have received. LPT needs to explore this further, and to agree the minimum level of experience and qualification necessary in medical practitioners in order to provide crisis resolution and home treatment professionals with the calibre of assessment and advice required when making decisions regarding home treatment as an alternative to admission. Note: Although the IIT has been advised that crisis resolution and home treatment team staff have been reminded about utilising out of hours medical staff during the assessment process, there is nothing specific in the July 2010 draft of the operational policy. If this remains absent, then LPT must make explicit its rationale for not addressing this to East Midlands SHA. Show less

7 Executive Director of Quality & Innovation, Director of Risk Assurance, the lead clinician for the crisis resolution and home treatment service, the crisis resolution team senior mental health practitioners and the Service Manager for LPT crisis resolution teams.

No Response Published

Recommendation

The managers of LPT’s crisis resolution and home treatment service must map out the core and specialist knowledge, skills and competencies required of mental health professionals working within the service and ensure that all of its staff meet these competencies. … Read more

8 Executive Director of Quality & Innovation, Director of Risk Assurance.

No Response Published

Recommendation

LPT must continue to ensure that all clinical staff are aware of issues that may affect a service user’s fitness to drive, and ensure that they know what measures they can take to deliver their duty of care to the … Read more

9 Assistant Director, High Secure Services and Healthcare Governance, East Midlands SHA.

No Response Published

Recommendation

East Midlands Strategic Health Authority is requested to liaise with the Department of Health to determine the best way to explore with the DVLA the issue of communication with medical practitioners following its assessment of an individual’s fitness to drive. … Read more