Independent investigation: Zaki Oettinger, Croydon (2013)

The Independent Investigation Team recognises the considerable amount of work completed by the Trust including the reconfiguration of services and the introduction of the single point of access. However, in order to ensure that the learning from the care and … Read more The Independent Investigation Team recognises the considerable amount of work completed by the Trust including the reconfiguration of services and the introduction of the single point of access. However, in order to ensure that the learning from the care and treatment of Donna has become embedded in the Trust’s current practice, the Independent Investigation Team recommends that the Trust conduct an audit of the efficacy of the receipt of information from out with the Trust in order to determine the action taken by the Trust in response to such a referral. Show less

1. MAP Trainee Psychiatrist 1 was in an early stage of his clinical practice as a psychiatrist. The complaints made about the care of Donna by her mother would have given his clinical supervisor an opportunity to ensure that there … Read more 1. MAP Trainee Psychiatrist 1 was in an early stage of his clinical practice as a psychiatrist. The complaints made about the care of Donna by her mother would have given his clinical supervisor an opportunity to ensure that there were no patient issues involved in Donna’s care as well as presenting a training opportunity for a junior doctor. 2. It is recommended that the Trust introduce a protocol regarding the response by the supervisor to a complaint involving the care of the patient being treated by a junior doctor. This protocol should include the following elements: a) Highlight early warning signs that a trainee maybe struggling; b) Early meeting with the patient or their carer and the supervisor; c) The option to transfer care to another clinician. Show less

1. It is recommended that the Trust considers whether an IT solution could be adopted which manages patients’ need for information about their inclusion on waiting lists. 2. The Trust should review the manner in which it communicates with the … Read more 1. It is recommended that the Trust considers whether an IT solution could be adopted which manages patients’ need for information about their inclusion on waiting lists. 2. The Trust should review the manner in which it communicates with the patients of its psychological therapy services who are awaiting access to the service in order to ensure that the use of reverse opt-in processes is avoided. 3. Staff are appropriately trained to provide accurate information in response to queries about Trust services, likely waiting times and other sources of assistance. 4. The Trust is to undertake an audit of correspondence produced in relation to waiting list management in order to determine whether all written communications reflect aims and ethos of the service and seeks to promote a positive engagement with potential service users which encourages a sense of hope. 5. The Trust should develop a protocol to provide guidance about information sharing in relation to the situation where a patient is receiving care from the private sector. Show less

Commissioners should consider conducting an impact assessment prior to the commissioning of ‘new’ services in order to establish the potential impact upon existing services in terms of staffing and recruitment in existing services.

The Trust is required to implement a suicide awareness training programme for its staff which addresses the following elements of care: a) the need to create and preserve hope; b) assist people to work through suicide towards achievable recovery and … Read more The Trust is required to implement a suicide awareness training programme for its staff which addresses the following elements of care: a) the need to create and preserve hope; b) assist people to work through suicide towards achievable recovery and growth goals; c) integrate suicide care into recovery care. It is recommended that implementation of this recommendation is audited by the Trust 6 months after inception of the training programme in order to assess its effectiveness. Show less

The Independent Investigation Team recommends that in teams which are identified as ‘failing’ or of being at ‘risk’, an immediate management plan should be initiated by an individual who is not connected in the line management of the failing team … Read more The Independent Investigation Team recommends that in teams which are identified as ‘failing’ or of being at ‘risk’, an immediate management plan should be initiated by an individual who is not connected in the line management of the failing team which seeks to: 1. Identify risk to new and existing patients of the current administrative processes and protocols; and, 2. Establish whether any immediate practical steps can be taken to reduce risk to patients notwithstanding action taken with regard to long term solutions such as seeking increased funding. Show less

In order to ensure that the learning from the care and treatment of Donna in relation to the supervision of Trainee Psychiatrist 1 has been established, the Independent Investigation Team recommends that an audit be undertaken by the Trust of … Read more In order to ensure that the learning from the care and treatment of Donna in relation to the supervision of Trainee Psychiatrist 1 has been established, the Independent Investigation Team recommends that an audit be undertaken by the Trust of the following: 1. An audit of the complaints made against trainees to establish any trends, in order to support the needs of trainees involved and the training provided by the Trust in general. 2. The Independent Investigation Team recommends the introduction of a protocol for supervisors as to how to respond to a complaint about a trainee, whether made through the formal complaints process or otherwise. The Trust should audit the implementation and use of the protocol 6 months after its introduction. Show less

It is recommended that the Trust review the Operational Policy: PMIC Assessment & Liaison Service (November 2016: Version 5) in order to ensure that all process noted within the policy are clear and accommodate the needs of all groups of … Read more It is recommended that the Trust review the Operational Policy: PMIC Assessment & Liaison Service (November 2016: Version 5) in order to ensure that all process noted within the policy are clear and accommodate the needs of all groups of service users. Show less

It is recommended that: 1) The Trust reviews its training requirements for individuals who are tasked with responding to complaints to ensure that the duty of openness is applied to all complaints, in order to ensure that all elements of … Read more It is recommended that: 1) The Trust reviews its training requirements for individuals who are tasked with responding to complaints to ensure that the duty of openness is applied to all complaints, in order to ensure that all elements of complaints are addressed accurately. 2) The Trust reviews its complaints policy to ensure that complaints are used as a vehicle to drive improvements in care. Show less

It is recommended that: 1. The ethos of the CPA should be reflected and strengthened in the training programmes which Trust staff are required to attend. 2. Every 6 months, a random audit of 10% of current individual service users’ … Read more It is recommended that: 1. The ethos of the CPA should be reflected and strengthened in the training programmes which Trust staff are required to attend. 2. Every 6 months, a random audit of 10% of current individual service users’ records are audited by the Managers in each service involved in the individual’s care with a view to establishing: a) Whether CPA is being correctly applied and adhered to; b) Whether all service users’ risk assessments are up to date; c) Whether staff are having regular supervision which includes reference to providing care which recognises the ethos of CPA; 3. Adherence to this recommendation is audited by the Trust on a 6-monthly basis. Show less

The Independent Investigation Team recommends a Trust faced with a similar situation in future must treat the families of victims as individuals. As a result, the Trust must acknowledge the personal knowledge levels of the case itself. The Trust must … Read more The Independent Investigation Team recommends a Trust faced with a similar situation in future must treat the families of victims as individuals. As a result, the Trust must acknowledge the personal knowledge levels of the case itself. The Trust must review its ‘Being Open Policy’ with a view to include guidance for internal investigation teams in relation to: 1. Demonstrate an understanding and sensitivity to the traumatic events family members with whom they will be have endured. 2. Arrangements surrounding meetings with families and carers following an incident are made with a view to minimising distress to all those involved. 3. Conflicts in evidence between must be explored in reports in order to demonstrate that the evidence given by family members has been taken into consideration. Show less

The Trust must conduct regular audits to ensure that its managerial supervision policies and procedures to facilitate supervision are being used to promote the delivery of service user centred long-term care. The audit process should include scrutiny of current samples … Read more The Trust must conduct regular audits to ensure that its managerial supervision policies and procedures to facilitate supervision are being used to promote the delivery of service user centred long-term care. The audit process should include scrutiny of current samples of actual care delivery at every level to ensure clinical practice reflects the delivery of service user care viewed from a long-term perspective. Show less