Independent investigation: Rina Panchal, Thurmaston, Leicester (2007)

Midlands

Incident 03 Jan 2007

Subject Rina Panchal

Mentally ill man fatally stabs shopworker. MH history

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)

1 LPT’s Chief Operating Officer, all service managers responsible for the teams listed above.

No Response Published

Recommendation

LPT must review the interface between operational policies of teams operating within Adult Services. LPT must ensure that at minimum the operational policies pertaining to:  inpatient services;  community mental health services;  Leicester City and Leicester County crisis … Read more

2 LPT’s Chief Operating Officer, Service Manager for the CRHT teams (city and county), Service Manager for Inpatient Services.

No Response Published

Recommendation

LPT should improve its early discharge planning This investigation identified that it is not the expected practice for LPT’s crisis resolution and home treatment (CRHT) services to receive a copy of the discharge plan for a MHSU taken on for … Read more LPT should improve its early discharge planning This investigation identified that it is not the expected practice for LPT’s crisis resolution and home treatment (CRHT) services to receive a copy of the discharge plan for a MHSU taken on for early discharge from inpatient services. Neither is it customary for CYPS to receive a copy of the discharge plan where there is known Adult Services and CYPS involvement within the same home. CRHT services If the provision of support at home by a CRHT service is an aspect of a discharge plan, it seems sensible to ensure that all parties to the plan have access to it. The CRHT service cannot be expected to meet the requisite quality standards unless provided with full and complete information when assuming the responsibility for the care of a MHSU. Consequently it is recommended with immediate effect that whenever a MHSU is accepted for early discharge then the CRHT team is provided with:  a copy of, or access to, the discharge plan; and  a copy of, or access to, the most up to date risk assessment. Ref: “Guidance statement on fidelity and best practice for crisis services”, DH, 2007 In adopting this recommendation LPT may wish the CRHT service to adopt the practice model currently used by PIER, namely going to the relevant team base and photocopying all previous records deemed important to have on PIER’s independent file. Note: The principles highlighted in this targeted recommendation apply to all discharge planning activities. They are not unique to early discharges. Children and Young People’s Services (CYPS) LPT needs to look at the guidance it provides to its staff regarding the provision of information to CYPS when both agencies are providing a service to the same family. The IIT appreciates that mental health practitioners will have anxieties about this and the rights of the individual MHSU. However the Local Safeguarding Children Board for Leicester, Leicestershire and Rutland has a clear statement of intent in its practice guidance entitled “Practice guidance adult mental health and child protection”. The former Department for Children, Schools and Families1 also provided guidance on information sharing and recommended greater collaboration in working practices within and across agencies. 1 Now the Department for Education The need for collaborative working, particularly with respect to agencies working for the protection of vulnerable adults and children, must be addressed or at least referenced within all operational policies for LPT services. LPT might also consider practical guidance on obtaining early consent from MHSUs for enabling effective and complete cross agency communication when necessary. In the immediate acute phase of mental illness this will not be appropriate and/or possible. However once a MHSU has been stabilised the discussion and formal obtaining of consent may be appropriate in many situations. LPT must also ensure that professional staff working in Adult Services are fully conversant with the following publications:  The Local Safeguarding Children Board’s guidance on information sharing: “Practice guidance adult mental health and child protection” (2009).  The Social Care Institute for Excellence (SCIE) publications, SCIE Guide 30: “Think child, think parent, think family: a guide to parental mental health and child welfare” (July 2009) and “At a glance 9: “Think child, think parent, think family” (July 2009).  The Department of Health’s guidance: “Information sharing and mental health” (September 2009). Ideally LPT will develop its own local policy documents relating to these issues that effectively distil key practice principles and provide clear and accessible guidance to frontline staff. Show less

3 LPT’s Chief Operating Officer, Service Manager for the CRHT teams (city and county).

No Response Published

Recommendation

LPT must achieve clear standards for discharging service users from CRHT services The IIT is aware that LPT is presently undertaking a complete overhaul of the way the CRHT service operates across Leicestershire with a view to rewriting operational policy. … Read more

4 Interim Divisional Director, Social Care & Safeguarding, Children and Young People's Services

No Response Published

Recommendation

For Leicester City Council’s Children and Young People’s Services (CYPS) need to consider producing a guidance note on core information it requires from other agencies in preparation for reports where professionals cannot attend for multi-agency meetings. The IIT understands that … Read more