Jump to 48 Recommendations

Independent investigation: Sharon Moore, Lisburn (2003)

Northern Ireland
Incident 09 Mar 2003
Subject Sharon Moore

Paranoid Schizophrenic fatally stabbed and mutilated woman, a month after release from Psych hospital. Ind Inq 2006. Known risk of violence to others, just released from Psych hospital

Report PDF Hundred Families
Acceptance Status
No Response Published 48
Total Recommendations 48
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 (48)

1 the Board
No Response Published
Recommendation
It is the panel’s clear view, and our first recommendation, that the Board should publish this report, and that it should provide copies, in advance, to the two families involved. In support of this recommendation we have not used the … Read more
10 the Trust (and others delivering similar services)
No Response Published
Recommendation
We recommend that the Trust (and others delivering similar services) should seek the assistance of the National Patient Safety Agency (NPSA) to train staff in the techniques of Root Cause Analysis (RCA), and that they should then develop policies and … Read more
11 this and other Trusts
No Response Published
Recommendation
Other policies that we have considered differentiate between, and provide definitions of, untoward incidents and serious untoward incidents. They provide categories of incidents, with each category requiring a different response for which clear instructions are given. There is also a … Read more
12 the Trust
No Response Published
Recommendation
We recommend that the Trust’s response to homicides should be included in revised policies and procedures on Serious Untoward Incidents, rather than forming a stand-alone policy.
13 nursing staff
No Response Published
Recommendation
We recommend that nursing staff who receive a patient into their care from the police or ambulance staff should exchange contact information with those staff. Nurses should record this information, together with the time of transfer, on the patient’s file. … Read more
14 the Trust
No Response Published
Recommendation
In the panel’s view, admission to and discharge from adult mental health in-patient facilities should be considered a single process that provides staff with a framework for providing structured and continuous care. Our recommendation is that the Trust’s Procedures for … Read more
15 the Trust
No Response Published
Recommendation
The panel recommends that risk assessment should be included, or cross-referenced, in an Admission and Discharge policy. The panel has noted the section of the 2004 Guidance on ‘Identification of those at-risk prior to discharge’ and would endorse its contents … Read more
16 Trusts
No Response Published
Recommendation
We recommend that relevant policies, particularly those pertaining to the delivery of care from the point of admission to the point of discharge, explicitly detail the Primary Nurse role. The duties and responsibilities of the role should be defined, as … Read more
17 the Trust
No Response Published
Recommendation
We recommend that the Trust must ensure that there is an adequate Assessment and Management of Risk Policy. The policy must be clear on responsibilities, how and when risk is to be assessed, managed and reviewed, and how records should … Read more
18 medical and nursing staff
No Response Published
Recommendation
We recommend that the initial risk assessment should be completed through joint assessment by the doctor and nursing staff. If a joint interview with the patient is not immediately possible or desirable, then medical and nursing staff should come together, … Read more
19 the hospital
No Response Published
Recommendation
We recommend that when police are involved in an admission because of a patient’s aggression or violence, all relevant details should be obtained from the police, by the hospital, including previous instances of aggression or violence. Such action should also … Read more
2 all Trusts
No Response Published
Recommendation
Evidence heard by the panel could be interpreted as suggesting that the Form 5 is used in Lagan Valley Hospital as a ‘stop-gap’ pending the arrival of the Consultant, and that it is subject to veto by other hospital staff. … Read more
20 Trusts
No Response Published
Recommendation
Assessment and Management of Risk is applicable to all service users. However, we recommend that a full risk history (including neglect, exploitation and other vulnerabilities as well as violent and aggressive behaviour) should be undertaken on those patients considered to … Read more
21 Trusts
No Response Published
Recommendation
We recommend that the Observations policy should explicitly refer to the ‘Assessment and Management of Risk’ policy as one that is linked to it. There is also an obvious link to the Admissions and Discharge policy and this should be … Read more
22 the Trust
No Response Published
Recommendation
We recommend that the Trust should consider the introduction of a “Level of Observations Record” which would provide a co-signed record of decisions taken on the levels of observations to be applied. This would be retained prominently in the file … Read more
23 Trusts
No Response Published
Recommendation
We recommend that all patients’ observations levels should be formally reviewed at least once a week (at the multi-disciplinary Team Assessment Meeting (TAM)), discussed with the patient and carers and decisions (including “no change”) documented in the file. Read more
24 Trusts
No Response Published
Recommendation
We recommend that decisions on patients being allowed to leave the Unit (e.g. ground pass, hourly pass, day pass etc.) should be covered by the Leave Policy. In this context, clear responsibilities should be established regarding decision-making for these ‘passes’ … Read more
25 Trusts
No Response Published
Recommendation
We would endorse the existing Leave policy’s requirement that the decision to agree to a patient going on planned leave should normally be taken by the multi-disciplinary team at the TAM. We further recommend that this decision should be documented … Read more
26 Trusts
No Response Published
Recommendation
We recommend that the Leave Policy should contain provisions requiring staff to inform the patient and carer/family about crisis and contingency planning in the event that something goes wrong during the period of leave. Staff should also provide a point … Read more
27 Trusts
No Response Published
Recommendation
We recommend that the policies (and procedures) on Observations and Leave should be explicitly cross-referenced.
28 the Trust
No Response Published
Recommendation
We acknowledge that it may be difficult for one file to cover both care in the community and periods of in-patient admission. However, we believe it is entirely practical for all multi-disciplinary records to be kept in one section of … Read more
29 nursing staff
No Response Published
Recommendation
We recommend that nursing staff should be encouraged to follow the recommended practice found in Guidelines produced by the Nursing & Midwifery Council (NMC): ‘Guidelines for records and record keeping’.
3 Trusts
No Response Published
Recommendation
We believe the Consultant did not act illegally in stopping the process begun by the completion of a Form 5. However, we would recommend that once the process has begun it should normally be allowed to continue, with appropriate contact … Read more
30 multi-disciplinary team
No Response Published
Recommendation
We recommend that all information available at the time of a multi-disciplinary team meeting (e.g. reports of aggressive behaviour) should be evaluated by the team, particularly in terms of re-assessment of risk, observations level and leave status, and that decisions … Read more
31 Trusts
No Response Published
Recommendation
We recommend that all notes documented in patients’ files should record the actual, or approximate, time of events.
32 the Trust
No Response Published
Recommendation
We recommend that the Trust’s Report Writing and Record Keeping Policy should have a clear section on record-keeping. The Trust may even wish to consider separating the two into two different policies. Either way, the revised policy should incorporate our … Read more
33 the Trust
No Response Published
Recommendation
We recommend that the Trust’s AWOL policy should provide greater clarity about staff’s responsibilities when voluntary patients are AWOL, including the need to alert the Consultant and senior management at an earlier stage than was done in this case. This … Read more
34 Trusts
No Response Published
Recommendation
We recommend that the AWOL policy should be put into effect immediately when a patient is noticed to be missing. The policy, however, needs to cater for the circumstances where a patient, either voluntary or detained under the Mental Health … Read more
35 Trusts
No Response Published
Recommendation
We recommend that the AWOL policy should be clear that the Nurse-in-charge at the time of an AWOL ‘event’ is responsible for arranging the immediate actions under the policy (organising a search, informing the senior nurse, (whether on-site or on-call) … Read more
36 Trusts
No Response Published
Recommendation
We recommend that the AWOL policy should establish clear categories of risk under which the patient should be assessed when his absence is noted. The Nurse-in-charge should be identified as having responsibility for considering the most recent risk assessment, (including … Read more
37 Trusts
No Response Published
Recommendation
We recommend that the AWOL policy should require that next of kin/carers be given advice about what to do if they locate the patient, and given a specific contact point or communication channel for use in such circumstances, and for … Read more
38 the Trust
No Response Published
Recommendation
We recommend that the Trust consider the development of a standard ‘AWOL form’ which could be used to prompt specific actions and to capture information likely to be of use if the police are involved. This may include information on … Read more
39 Trusts
No Response Published
Recommendation
We recommend that the AWOL policy should include both immediate and longer-term actions, which should be proportionate to the assessed level of risk. Action might, for example, include a multi-disciplinary review, from which a clear plan of action should emerge. … Read more
4 Trusts
No Response Published
Recommendation
The panel agreed that the term “Detain if wishes to leave” is not a satisfactory one. It is clearly open to interpretation. It is not in keeping with the processes required under the Mental Health (Northern Ireland) Order 1986 and … Read more
40 Trusts
No Response Published
Recommendation
We recommend that an action plan emerging from a multi-disciplinary review should include identification of a person responsible for informing all others involved in a patient’s care in the community (e.g. GP, CPN, Social Worker, Day Centre, Hostel management, carers, … Read more
41 Trusts
No Response Published
Recommendation
We recommend that the action plan should include provision to make hospital staff aware of what they should do if the patient should appear at the hospital, and how they are expected to co-operate with family, carers and the police. … Read more
42 the Trust
No Response Published
Recommendation
We recommend that the Trust should consider retraining for all staff who may be faced with responding to an AWOL situation. In addition, the AWOL policy should be quite clear that the nurse in charge should take the lead when … Read more
43 Trusts
No Response Published
Recommendation
The panel endorses the following recommendations from the ‘Safety First Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental illness - 2001’: • “services should make provision for patients with severe mental illness and … Read more
44 the Department
No Response Published
Recommendation
While it is our hope that the Trust will ensure that its current service provision lives up to these recommendations, we would also recommend that the Department should ensure that the services recommended above are among those that are commissioned … Read more
45 the Trust
No Response Published
Recommendation
We recommend that the Trust should develop a procedure by which community mental health staff remain actively involved after their patients’ admission to hospital, and that they are also involved in discharge planning for individual patients back into the community. … Read more
46 the Trust
No Response Published
Recommendation
We recommend that the development of supervision arrangements, proposed in the Trust’s Learning and Development Strategy and Action Plan 2005-2008 (Draft 2), must address Clinical Supervision. This should include clear identification of responsibility for putting in place a written policy … Read more
47 the Trust
No Response Published
Recommendation
We recommend that the Trust undertakes appropriate assessment of training needs to ensure that training provision is focused on individuals’ continued professional development and organisational needs, and that a multi-disciplinary approach to training should be facilitated where appropriate. Read more
48 the Trust and the responsible Board
No Response Published
Recommendation
In order to maximise confidence in, and to protect the integrity of, any investigation (whether internal or external) the panel recommends that the Trust should make it standard practice for all papers relevant to a patient’s care (from whatever source … Read more
5 the Department
No Response Published
Recommendation
We recommend that the Department put in place a robust audit of each service provider’s implementation of the May 2004 Guidance on ‘Discharge from Hospital and the Continuing Care in the Community of People with a Mental Disorder who could … Read more
6 the Department
No Response Published
Recommendation
While we believe that much of the 2004 Guidance could be implemented without significant additional resources, we recommend that the Department should consider providing whatever resources prove necessary for the re-training of staff in new responsibilities outlined in the Guidance, … Read more
7 the Trust
No Response Published
Recommendation
We recommend that the Trust should ensure that there are formal guidelines in place for its community staff to follow in ‘loss of contact’ cases and that these are brought to the attention of all community staff.
8 Trusts
No Response Published
Recommendation
We further recommend that all care plans (for those who meet the criteria under the 2004 Guidance) should include relapse indicators and crisis and contingency planning, particularly in relation to loss of contact with services.
9 Trusts
No Response Published
Recommendation
The panel recommends that all policies and procedures should: • be developed with multi-disciplinary input and include user/carer consultation where appropriate; • be signed off at Trust Board level; • clearly state the purpose of the policy; • include reference … Read more