Independent investigation: Ramatunnessa Choudhury, Luton (2010)

East of England

Incident 25 Jun 2010

Subject Ramatunnessa Choudhury

Paranoid schizophrenic repeatedly beat mother to death in front of children. Long MH history with serious violence. Not taking meds

Report PDF Hundred Families

Acceptance Status

No Response Published 4

Total Recommendations 4

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 (4)

Recommendation 1 The Trust’s Executive Director responsible for Patient Safety, The Executive Director of Forensic Services.

No Response Published

Recommendation

The Independent Team has been provided with a copy of the proposed new policy document, “Policy on the Transfer of Clients From Low Secure Services”. Detailed constructive commentary has been provided to the authors of the document via The Trust’s … Read more

Recommendation 2 The Executive Medical Director and Executive Director of Clinical Governance and Quality, the Executive Directors of Integrated Services Bedford and Luton; and Essex, and the Executive Director of Forensic Services.

No Response Published

Recommendation

Building on Recommendation 1, The Trust is recommended to conduct a multi-disciplinary Failure Modes and Effects Analysis2 (FMEA), or Control / Barrier Analysis across the forensic and general adult psychiatric service of its “Policy on the Transfer of Clients From … Read more

Recommendation 3 The Trust’s Executive Director of Clinical Governance and Quality.

No Response Published

Recommendation

Although the Trust’s investigation utilised nationally available guidance templates during the conduct of its investigation, and in principle met with the then and currently required investigation standards, there were a number of features of the Mr H investigation that could … Read more Although the Trust’s investigation utilised nationally available guidance templates during the conduct of its investigation, and in principle met with the then and currently required investigation standards, there were a number of features of the Mr H investigation that could have been improved on if the Trust is to optimise opportunities for effective learning, and the consistent delivery of an effective investigation. The Independent Team recognises that this recommendation represents a ‘gold standard’ in the conduct of adverse event reviews, but it considers that SEPT has the necessary commitment at Executive and local levels of the organisation to deliver investigations of a higher quality. To achieve this, the areas of investigation practice that the Independent Team considers the Trust may wish to consider are: • The clear formulation of core competencies for all investigators tasked with the conduct of high impact/ high consequence incidents such as the case of Mr H. These core competencies might include: (cid:1) Knowledge of a range of investigation techniques such as analytical Timelining, Control Analysis, Person / Placement grids (cid:1) Knowledge of how to conduct a repeatable information analysis using tried and tested qualitative research techniques such as Content Analysis and Affinity Mapping (cid:1) Knowing what issues to conduct a contributory factors analysis on (cid:1) Investigative Interviewing, including question formulation such as the “tell all” instruction, reflect back, and effective note taking (cid:1) The quality of interview records made. Attention needs to be given to interview records that are data rich, and reflect the full depth and breadth of the interview content, including evidence of ‘reflect back’. (cid:1) The Trust, as a component of the quality assurance standards must include consideration of the fairness with which lapses in practice have been addressed across all professional groups. Although not at all intended the Mr H report did not come across as balanced in its criticisms across the range of professional groups involved. In addition to the above points, specific and detailed guidance has been provided by the Independent Team to The Trust with regards to: • The conduct of the investigative interview; • The formulation and analysis of identified care concerns (significant lapses in practice standards). Show less

Recommendation 4 The Executive Director of Integrated Services Bedford and Luton

No Response Published

Recommendation

As a consequence of the Mr H case, The Trust undertook a root and branch review of the operational management and clinical leadership of community mental health teams. The intention was to achieve a wholesale improvement in clinical and operational … Read more