Independent investigation: Tamara Holboll, Kentish Town (2014)

Given the difficulties we have experienced obtaining the information we required during the investigation process, the Trust should implement a clear policy for ensuring that requests for information from independent investigations are met in a timely and efficient way. Read more Given the difficulties we have experienced obtaining the information we required during the investigation process, the Trust should implement a clear policy for ensuring that requests for information from independent investigations are met in a timely and efficient way. Show less

The operational changes to the Trust’s bed management system should be incorporated into the policy

Given our concerns and the Coroner’s, NHSE should refer this report to the Cavendish Square Group so that it may take forward learning from it with commissioners and providers in the capital. In particular, NHSE should emphasise its concern that … Read more Given our concerns and the Coroner’s, NHSE should refer this report to the Cavendish Square Group so that it may take forward learning from it with commissioners and providers in the capital. In particular, NHSE should emphasise its concern that every patient who is identified by mental health services as requiring a mental health bed in London should be allocated a bed. And that all London mental health trusts should actively monitor their ability to provide beds when they are needed and be alive to the risks of workarounds developing when bed pressures exist Show less

The guidance for people undertaking SI investigations for the Trust should emphasise that investigators need to distinguish between evidence obtained from the contemporary records and evidence from subsequent statements, and when appropriate challenge staff about any discrepancy. Read more The guidance for people undertaking SI investigations for the Trust should emphasise that investigators need to distinguish between evidence obtained from the contemporary records and evidence from subsequent statements, and when appropriate challenge staff about any discrepancy. Show less

The Trust’s Rehabilitation and Recovery Division should implement measures to provide assurance that risk assessments meet the necessary quality standards. In particular, all risk assessments should flag known relapse signs and proven risk management strategies Read more The Trust’s Rehabilitation and Recovery Division should implement measures to provide assurance that risk assessments meet the necessary quality standards. In particular, all risk assessments should flag known relapse signs and proven risk management strategies Show less

The Trust should ensure that its systems are capable of identifying when its service users are not registered with a GP and ensuring that GP registration then occurs.

The Trust should ensure that when its policies require it to communicate with a patient’s GP, that communication occurs.

It is recommended that NHS England ensure that people with a CPA care plan are not deregistered from their GP without contacting Adult Social Care and/or the Mental Health Trust first.

We recommend that the Trust’s Rehabilitation and Recovery Division reviews its systems for ensuring that all care episodes are recorded in line with its record keeping standards.

The Trust should ensure that the role of alcohol and drug misuse in heightening risk is emphasised sufficiently in its risk assessment and management procedures.

The role of the Crisis Team in assessing informal referrals should be clarified in policy given the principles in the concordat and the gatekeeping requirements. The aim should be to ensure a seamless and responsive assessment process for clients in … Read more The role of the Crisis Team in assessing informal referrals should be clarified in policy given the principles in the concordat and the gatekeeping requirements. The aim should be to ensure a seamless and responsive assessment process for clients in acute crisis and clarity as to responsibilities where different service areas have involvement in the patient’s care Show less

The Trust should review the measures taken by referrers to manage extended waits for beds in order to establish if any risks being taken can be better mitigated.