Independent investigation: William Kean, Canning Town (2004)

It is recommended that the Trust ensure that all relevant staff are compliant with the training provided by the Trust that takes into account safeguarding both adults and children when assessing risk and planning care. This should remain part of … Read more It is recommended that the Trust ensure that all relevant staff are compliant with the training provided by the Trust that takes into account safeguarding both adults and children when assessing risk and planning care. This should remain part of the initial and subsequent care planning process and audited in line with Trust policy including individual supervision and the application of CPA. Show less

Given the recommendation above in relation to Information Sharing, it is recommended that a risk history with details of violent incidents is incorporated in any clinical care planning process. The application of this should be audited as part of the … Read more Given the recommendation above in relation to Information Sharing, it is recommended that a risk history with details of violent incidents is incorporated in any clinical care planning process. The application of this should be audited as part of the regular CPA audit as set out below. Show less

It is recommended in accordance with best practice and to ensure that staff have the opportunity to check that the evidence they have given to internal reviews is accurate and reflects the issues that they wish to raise that all … Read more It is recommended in accordance with best practice and to ensure that staff have the opportunity to check that the evidence they have given to internal reviews is accurate and reflects the issues that they wish to raise that all interviews undertaken for internal reviews are recorded and transcribed verbatim. These transcriptions are for the purpose of ensuring the investigation team can also check and validate their findings, and not for inclusion in reports. Following NHS London‟s guidance it is further recommended that an independent investigator is a panel member for all cases of homicide. Show less

It is recommended that the Trust provides Dual Diagnosis training to all clinical staff and that this training is audited as to its effectiveness.

It is recommended that a summary sheet is developed to be sited at the front of patients‟ records and updated on a regular basis. This should include: o Current and Diagnostic History o Risk History with a detailed list of … Read more It is recommended that a summary sheet is developed to be sited at the front of patients‟ records and updated on a regular basis. This should include: o Current and Diagnostic History o Risk History with a detailed list of all violent incidents and any link to abnormal mental state o Risk Management Plan o Changing diagnosis if relevant o What medication worked well and problems with medication including allergic reactions o Admission history o Markers for relapse o Signs of relapse o Contingency plans to manage relapse o Current care team and contact details Show less