Kettering review

Northamptonshire Police to remind officers of the importance of considering the use of DVPN’s or DVPO’s even when the victim is refusing to engage with the investigation.

To review the electronic patient alert system and ascertain if any changes would support forced reading of alerts and implement changes that are possible.

Domestic abuse notifications should be considered as part of any risk assessment by mental health teams.

S2S to create a service pathway which will outline end to end MARAC procedures including a template for how MARAC information is recorded in case management systems.

Place flags on various KBC systems to contact relevant officer when we are actively trying to engage with victims of domestic abuse.

The author of this review will inform the Ambulance Operations Manager (AOM) of the outcome of the review and request that the attending crew members have up to date training on clinical record keeping.

There needs to be urgent action taken to ensure either CFN or the child’s maternal grandmother attain parental responsibility for the child. Strategic and Service managers put deadline of 5th Oct 2018 for Grandmother to be supported to complete and submit SGO application.

Northamptonshire Police to remind officers of the importance of completing a DASH risk assessment even if the victim refuses to cooperate.

Utilise the findings regarding the Mental Capacity Act issues within this report as a learning opportunity within training specifically related to documentation regarding consent

The inpatient teams should be made aware of the importance of contemporaneous record keeping and risk assessments. This should be shared learning at team meetings in relation to this case.

S2S ‘missed appointments check list’ will be audited regularly by designated county safeguarding leads to support all managers to monitor service users’ engagement, identify appropriate actions for case managers and reduce risk.

Make more persistent attempts to contact victims of domestic abuse.

On the conclusion of the IMR the author will complete a patient story, and lessons learnt article to be disseminated throughout the organisation. This will have the following specific information: Professional curiosity Importance in recognising vulnerable patients and the need to explore care and support needs. Requirement for crews to follow up verbal discussions with partner agencies with a referral. The need to obtain the names of all individuals on scene rather than writing “partner”

Support needs to be provided to the child and Grandmother following the loss their mother / daughter respectively. Social worker confirms support has been offer and Grandmother has chosen to address mother’s death and support the child herself. She herself prefers to have support from the family.

Northamptonshire Police should remind officers of the importance of maintaining contact with the victims of domestic abuse especially following referrals from the SFC.

Review of the Mental Capacity Act audit tool to include audit of review of Deprivation of Liberty Safeguards authorisations and implement any actions from findings to ensure compliance with the Mental Capacity Act.

Professional curiosity should be part of everyday practice, to ensure that patient’s accounts of events can be corroborated thus aiding a more accurate risk assessment and safety planning. NHFT staff to continue work within the boundaries of Information Governance and Information Sharing agreements to ensure best practice and care to our patients.

S2S to introduce a new protocol regarding discharge planning processes for all service users exiting the service to ensure that discharge planning is linked to wider governance arrangements.

CFN ensure supervision take places as per the Supervision Standards and there is management oversight to ensure actions are completed.

The Northamptonshire Police Domestic Abuse procedures should be regularly reviewed and updated to ensure that they remain fit for purpose.

CFN review its policy on the required level of management seniority needed to close a case to prevent cases closing prematurely.

Northamptonshire Police should continue to promote the roles of the DAPIT and SFC to ensure that officers and staff are aware of the additional support that exists.

CFN to use learning from this case to provide additional guidance / training to Social Workers / managers on legal status for children when CFN decide the child is unable to return to a parent’s care

Northamptonshire Police should remind supervisors the importance of actively managing investigations where the victim(s) are vulnerable and reluctant to engage with the police beyond the initial report. A more lateral problem-solving approach and awareness of previous incidents may assist with the successful resolution of the particular issue.

Northamptonshire Police to remind officers to consider evidence lead prosecutions, in conjunction with the CPS, in cases where the victim is refusing or reluctant to support a prosecution.

Consideration should be given to reviewing the quantity and effectiveness of the actions generated from MARAC and to establishing processes to ensure those actions are completed in a timely manner.

General Practice should utilise the IT tools available on their practice system to view all safeguarding codes collectively so that vulnerability and increasing risk can be identified in a timely manner and appropriate action taken to safeguard.

The development of an information sharing agreement between MARAC and practices would greatly enhance information sharing and allow practices to accurately code and have oversight for victims of DA in order to be able to assess risk and respond appropriately.

General practice clinicians should ensure that when DA is disclosed by an individual, a risk assessment is carried out. This will inform their management and enable victims to be signposted to the appropriate service.

Kettering Borough Council Housing Department to review its procedures regarding being proactive in taking steps to recover outstanding rent arrears.

Kettering Borough Council Housing Department to review its procedures regarding being proactive in responding to neighbour’s complaints and not relying on the community to identify problem area especially where incidents of domestic abuse are evident.