Independent investigation into the care and treatment of Ms Z in the North Midlands

The Trust take steps to unify paper and digital patient records. Until such time as the paper and electronic records have been unified, the Trust must implement a protocol to ensure a review of patient’s paper and electronic records is … Read more The Trust take steps to unify paper and digital patient records. Until such time as the paper and electronic records have been unified, the Trust must implement a protocol to ensure a review of patient’s paper and electronic records is undertaken at key stages (admission, CPA Review, discharge and transfer). Show less

Following unification of paper and digital record keeping systems, patients’ historical records must be reviewed and summarised at key stages in their care (admission, CPA Review, discharge and transfer).

The performance of the requirements at 1 and 2 and the adherence to protocol connected to these recommendations needs to be monitored and audited.

The findings of these audits are to form part of discussions at regular Quality Assurance Meetings.

The ethos of the CPA should be reflected and strengthened in the training programmes which Trust staff are required to attend.

Every 6 months, each individual service user’s CPA records are audited by the Managers in each service involved in the individual’s care with a view to establishing: 1. Whether CPA is being correctly applied and adhered to; 2. Whether all … Read more Every 6 months, each individual service user’s CPA records are audited by the Managers in each service involved in the individual’s care with a view to establishing: 1. Whether CPA is being correctly applied and adhered to; 2. Whether all service users’ risk assessments are up to date; 3. Whether staff are having regular supervision which includes reference to providing care which recognises the ethos of CPA. Show less

Adherence to this recommendation is audited by the Trust on a 6-monthly basis.

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.

“Consent to share” information should be updated regularly to promote effective communication between services, the service user and family members/carers. Protocols and policies should be introduced to secure this.

Close family members should always be given a contact point to access the mental health system in a crisis. Communication should be established as early as possible.

The Trust reviews its “family involvement strategy” to ensure that family members receive appropriate psychological as well as practical support.

In order to obtain a comprehensive understanding of the service user’s current psychiatric, social and family circumstances and risk characteristics, the Trust’s Quality Assurance Programme be revised to ensure that Teams are required to actively seek family members’ involvement and … Read more In order to obtain a comprehensive understanding of the service user’s current psychiatric, social and family circumstances and risk characteristics, the Trust’s Quality Assurance Programme be revised to ensure that Teams are required to actively seek family members’ involvement and views. Show less

Collateral histories should be taken from family members and/or carers to secure a greater insight into a service user’s situation and those of the family members/carers themselves.

In order to maximise the learning taken from Ms Z’s fatal attack upon the victim, approaches to serious incidents should take account of the “bigger picture” of a serious incident. For example, investigating how a crisis has developed should be … Read more In order to maximise the learning taken from Ms Z’s fatal attack upon the victim, approaches to serious incidents should take account of the “bigger picture” of a serious incident. For example, investigating how a crisis has developed should be as a means to identifying learning which can generate improvements in service delivery. The Independent Investigation Team recommends that the Trust’s framework for investigating serious incidents be reviewed to implement this Recommendation. Show less

The Trust takes active steps to ensure that staff and clinicians are supported in relation to serious incidents. In addition to this, the Trust must also take active steps to ensure that information is shared with staff and clinicians in … Read more The Trust takes active steps to ensure that staff and clinicians are supported in relation to serious incidents. In addition to this, the Trust must also take active steps to ensure that information is shared with staff and clinicians in a timely way, and that a longer term view of “support” is taken. Show less

The Trust must implement processes to ensure that the learning from adverse incidents and the action points which are generated are drawn to the attention of staff and clinicians involved in the events in order that learning can be embedded … Read more The Trust must implement processes to ensure that the learning from adverse incidents and the action points which are generated are drawn to the attention of staff and clinicians involved in the events in order that learning can be embedded in the day to day practices of those responsible for delivering care. Show less

The Trust must take steps to demonstrate greater awareness of the knowledge levels of family members of victims, their specific backgrounds and insights, and their interactions.