Independent investigation: Sally Hodkin, Bexley (2011)

The recommendations and action plan of the Trusts internal investigation should be reviewed to take account of the External Independent Investigation Panel additional findings.

The Trust should satisfy itself that the practice and approach sometimes taken by an RC in applying to the MoJ, rather than the patient seeking this through the MHA Tribunal, is acceptable.

The Trust should review the Bracton Centres communication with the MoJ, as correspondence to the MoJ did not fully reflect Ms A’s behaviour and presentation.

The Trust should review its practice and culture relating to communication with families and other stakeholders involved in the care of the patient, both during the CPA process, and during day to day management of care.

The Trust should ensure that robust processes are in place to support a clinical decision to allow patients who are on a conditional discharge to visit other countries.

The circumstances of this case highlight the need for a process by which the police and other emergency services are able to conduct, on arrival, an appropriate handover of the patient with appropriate health professionals regardless of the manner through … Read more The circumstances of this case highlight the need for a process by which the police and other emergency services are able to conduct, on arrival, an appropriate handover of the patient with appropriate health professionals regardless of the manner through which crisis mental health care is sought. The circumstances of the case also highlight the need for A&E departments and their Mental Health Trust partners to consider how the Mental Health Act powers are deployed in support of the crisis care pathway including the powers that may be enacted by the hospital alone. Show less

The Trust to review the uptake of training relating to risk assessment and management, and clinical observation, for all Mental Health Liaison Team staff to ensure staff are up to date.

The Trust should ensure an auditable process is in place to monitor communication between the A&E Department and the Mental Health Liaison Service, so that it remains effective.

The Trust should review the route undertaken by acutely mentally unwell patients, who are admitted via the MHLS to Oxleas House.

The Trust must ensure that given the new commissioning arrangements for Forensic Services, no gap is allowed to develop for Service Users who are forensic inpatients, but then discharged to the care of a general team.

The Trust should review their Duty Dr on-call arrangements to consider the use of a specific Dr on-call rota for the Forensic services.

Actions developed from additional recommendations must be auditable to ensure compliance.

MAPPA should hold a central database for those patients on Level 1 MAPPA.

NHS England should ensure that the terms of reference guide the Panel to identify where it may become necessary to invite additional Panel members with specialist knowledge of other organisations such as Police or Housing.

The Trust to ensure that the action plan continues to be monitored and its progress reported upwards via its governance reporting systems.

The Trust should ensure that all recommendations from Internal Investigations are SMART and auditable, leading to effective learning.

The Trust should ensure that all Policies identified within the report are updated to address the findings.

The Trust should ensure that all those involved or affected by a serious incident, have the opportunity to contribute to an investigation and to receive support.

The Trust should assure itself that leadership at both clinical and managerial level is effective.

The Trust should review the Practice of discharging conditionally discharged patients to low supported accommodation which does not have staffing over a 24 hour period.

The Trust should review the approach taken when patients on a ‘conditional discharge’ gain employment, in terms of communication with the employer and assessing the appropriateness of the job.