Independent investigation: Rebecca Sessacar, Croydon (2012)

The Trust must ensure that up to date, comprehensive care plans are in place for all patients under the care of liaison psychiatry, home treatment team and Croydon Triage, particularly those who have been detained under the Mental Health Act … Read more The Trust must ensure that up to date, comprehensive care plans are in place for all patients under the care of liaison psychiatry, home treatment team and Croydon Triage, particularly those who have been detained under the Mental Health Act and who are subject to Care Programme Approach. The Trust must also review and monitor an ongoing audit programme to provide assurance about organisational compliance with this requirement. Show less

The Trust must make the following amendments to the domestic violence policy so that it is in line with best practice: • clarify the Trust responsibility and commitment in providing the working environment and comprehensive training required in order that … Read more The Trust must make the following amendments to the domestic violence policy so that it is in line with best practice: • clarify the Trust responsibility and commitment in providing the working environment and comprehensive training required in order that practitioners are able to meet their obligations safely and effectively; • clarify the Trust response when it is identified that an employee is a perpetrator of domestic violence; • include more detailed responsibilities for responding when victims or perpetrators of domestic violence are identified within the workplace, including a protocol for reporting concerns about a colleague. • N.B. This recommendation is based upon our review against best practice and has no direct link with this incident. Show less

The Trust must provide a separate handbook on the process for responding to clients or carers affected by domestic violence, to give greater detail to staff outside of the Trust policy.

The Trust must review the Adult Safeguarding Policy to ensure that it provides staff with clear direction as to what steps to take to raise concerns about a vulnerable adult, particularly when that person is also a carer.

The Trust must ensure that prior to discharging a client there should be an appropriate discharge plan and risk assessment in place that are shared with appropriate community staff and other agencies. Where possible this plan should be agreed and … Read more The Trust must ensure that prior to discharging a client there should be an appropriate discharge plan and risk assessment in place that are shared with appropriate community staff and other agencies. Where possible this plan should be agreed and supported by the client and (subject to client consent) their carer. Show less

The Trust must identify all stakeholders required to be present on the Board Level Inquiry panel at the point that investigations are commissioned, in order to reduce delays in implementing lessons learned.

The Trust must manage clinical and organisational commitments appropriately to ensure that they do not cause delays in investigation of serious incidents and implementation of learning.

The Trust must review the detail of the actions taken in response to the complaint made by Miss N to assure themselves that the failures in investigating and communicating in a timely fashion cannot be repeated.

The Trust must ensure that risk assessments and risk management plans are in place for all patients under the care of liaison psychiatry, home treatment team and Croydon Triage, particularly those who have been detained under the Mental Health Act … Read more The Trust must ensure that risk assessments and risk management plans are in place for all patients under the care of liaison psychiatry, home treatment team and Croydon Triage, particularly those who have been detained under the Mental Health Act and who are subject to Care Programme Approach. They must also be reviewed when new information comes to light. The Trust must also review and monitor an ongoing audit programme to provide assurance about organisational compliance with this requirement. Show less

The Trust must ensure when assessments of clients who are in police custody are undertaken, that clinicians obtain a clear history from police staff about the client’s forensic history.

The Trust must ensure that all staff consider the role of carers and that carers assessments and appropriate support are offered and documented, this includes drawing up an accurate family diagram. The Trust must also review and monitor an ongoing … Read more The Trust must ensure that all staff consider the role of carers and that carers assessments and appropriate support are offered and documented, this includes drawing up an accurate family diagram. The Trust must also review and monitor an ongoing audit programme to provide assurance about organisational compliance with this requirement. Show less

The Trust must review the impact of the changes to policy and processes for child safeguarding, including obtaining feedback from staff about how effective the new processes are.

The Trust must ensure that when a diagnosis is recorded appropriate plans are put into place for ongoing treatment and support and this is reviewed and amended, if appropriate, when any changes to the diagnosis are made The Trust must … Read more The Trust must ensure that when a diagnosis is recorded appropriate plans are put into place for ongoing treatment and support and this is reviewed and amended, if appropriate, when any changes to the diagnosis are made The Trust must ensure that when changes are made to a patient’s diagnosis, the management plan must be revised accordingly and must be consistent with the revised diagnosis and the patients’ needs. Show less

The Trust must clarify the care pathway for patients with personality disorder and ensure that staff are aware of the referral criteria for access to psychological services.

The Trust must ensure that processes are in place to trace the correct GP for clients when a client record indicates that a client is not registered with a GP; and that this must be undertaken within seven calendar days.

The Trust and Croydon Health Services Trust must ensure when a patient attends A&E for treatment and is seen by the liaison psychiatry service that appropriate records of that attendance and any interventions are recorded in line with both organisational … Read more The Trust and Croydon Health Services Trust must ensure when a patient attends A&E for treatment and is seen by the liaison psychiatry service that appropriate records of that attendance and any interventions are recorded in line with both organisational record keeping policies. Show less

The Trust must ensure that community staff understand and comply with the lone working policy and that staff read the records and undertake an appropriate risk assessment about the home visit prior to leaving Trust premises.